a nurse receives report about assigned clients at the start of the shift which of the following clients should the nurse plan to see first
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ATI RN

ATI Maternal Newborn Proctored Exam 2023

1. A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

Correct answer: A

Rationale: The nurse should prioritize seeing the client who experienced a cesarean birth 4 hours ago and reports pain first. Pain assessment and management are crucial post-cesarean birth to ensure the client's comfort and well-being. Immediate attention is needed to address the client's pain and provide appropriate interventions. The other clients may require attention but do not have an immediate postoperative concern like pain following a cesarean birth.

2. 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?

Correct answer: C

Rationale: Preeclampsia is characterized by elevated blood pressure, proteinuria, and sometimes edema. Hypertension is a key sign of preeclampsia, and if present, further evaluation and monitoring are necessary to prevent complications for both the mother and the fetus.

3. A healthcare provider in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the provider the presence of intra-abdominal bleeding?

Correct answer: B

Rationale: Cullen's sign is the presence of periumbilical ecchymosis indicating intra-abdominal bleeding, which can be associated with a ruptured ectopic pregnancy. Chvostek's sign is a facial spasm related to hypocalcemia. Chadwick's sign is a bluish discoloration of the cervix, vagina, and labia during early pregnancy. Goodell's sign is a softening of the cervix in early pregnancy.

4.

Correct answer: C

Rationale:

5. 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.

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