a nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia which of the following is an ex
Logo

Nursing Elites

ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. During the admission assessment of a client at 38 weeks of gestation with severe preeclampsia, what would the nurse expect as a finding?

Correct answer: D

Rationale: Severe preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. Headache is a common symptom in clients with severe preeclampsia due to cerebral edema or vasospasm. Tachycardia (Choice A) is not typically associated with severe preeclampsia. Clonus (Choice B) is a sign of hyperactive reflexes, often seen in clients with severe preeclampsia. Polyuria (Choice C) is not a typical finding in clients with severe preeclampsia.

2. A client at 37 weeks of gestation with severe gestational hypertension is being admitted by a nurse. Which of the following actions should the nurse NOT expect to implement?

Correct answer: C

Rationale: Assessing respiratory status every 4 hours is not a priority for a client with severe gestational hypertension. In this scenario, the focus should be on monitoring blood pressure, assessing for signs of preeclampsia, administering medications like magnesium sulfate for seizure prophylaxis, and ensuring that calcium gluconate is readily available in case of magnesium toxicity. Respiratory status assessment is important in other conditions but is not directly related to managing severe gestational hypertension.

3. A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?

Correct answer: A

Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.

4. A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

Correct answer: D

Rationale:

5. A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Correct answer: D

Rationale: The correct intervention for a client who is 2 hours postpartum following a cesarean birth with a history of thromboembolic disease is to have the client ambulate. Early ambulation is crucial in preventing complications such as deep vein thrombosis in postpartum clients. Applying warm, moist heat, massaging the legs, or placing pillows under the knees do not directly address the risk of thromboembolic disease in this scenario.

Similar Questions

A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. Following an examination, the provider informs the client that the fetus has died, indicating a:
A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?
A client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios is found to have which of the following?
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses