ATI Protected Maternal Newborn

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Sample questions from ATI Protected Maternal Newborn

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 28-year-old client at 34 weeks of gestation arrives at the maternity triage unit with painless bright-red vaginal bleeding. The fetal heart rate is 140/min, blood pressure is 118/72 mm Hg, and the client reports normal fetal movement. Which action should the nurse take first?

   • A.Perform a digital cervical examination to assess dilation
   • B.Apply external fetal monitoring and assess maternal status
   • C.Encourage the client to ambulate to determine whether bleeding increases
   • D.Prepare the client for an immediate induction of labor

   Rationale: External fetal monitoring and maternal assessment are priorities because painless bleeding may indicate placenta previa, which can cause sudden hemorrhage. A digital examination and ambulation could provoke severe bleeding, and induction is not appropriate before the cause and maternal-fetal status are evaluated. With third-trimester bleeding, avoid vaginal examinations until placenta previa is excluded.

2. 2.A 31-year-old client at 32 weeks of gestation is admitted with severe preeclampsia. The client is receiving magnesium sulfate at 2 g/hr; respirations are 10/min, deep tendon reflexes are absent, and urine output is 20 mL/hr. Which action should the nurse take first?

   • A.Increase the magnesium sulfate rate to prevent seizures
   • B.Stop the infusion and prepare to administer calcium gluconate
   • C.Place the client supine and reassess in 30 minutes
   • D.Administer an oral antihypertensive medication

   Rationale: Respiratory depression, absent reflexes, and oliguria indicate magnesium toxicity, so the infusion should be stopped and the antidote prepared. Increasing the rate worsens toxicity, the supine position can impair venous return, and an oral antihypertensive does not treat magnesium toxicity. Monitor respirations, reflexes, and urine output during magnesium therapy.

3. 3.A 24-year-old client at 39 weeks of gestation is in active labor with an epidural infusion. The client's blood pressure falls from 122/76 to 86/48 mm Hg, and the fetal heart rate decreases to 95/min. What should the nurse do first?

   • A.Assist the client to a lateral position
   • B.Increase the epidural infusion rate
   • C.Encourage the client to bear down
   • D.Prepare for immediate operative vaginal birth

   Rationale: Lateral positioning can improve venous return and uteroplacental perfusion when epidural-associated hypotension accompanies fetal bradycardia. Increasing the epidural may worsen hypotension, pushing is not indicated without complete dilation, and operative birth is premature before initial resuscitative measures. Reposition first while promptly notifying the appropriate clinician and continuing fetal assessment.

4. 4.A 35-year-old client at 37 weeks of gestation reports a severe headache and seeing flashing lights. Blood pressure is 168/112 mm Hg on repeat measurement, and urine protein is 3+. Which prescription should the nurse anticipate?

   • A.Administer an antihypertensive medication and magnesium sulfate
   • B.Encourage oral fluids and recheck blood pressure in 4 hours
   • C.Administer a tocolytic medication to prevent labor
   • D.Discharge the client with instructions to rest at home

   Answer and rationale are in the full material.

5. 5.A 29-year-old client at 30 weeks of gestation is hospitalized with preterm prelabor rupture of membranes. Temperature is 37.0 C (98.6 F), fetal heart rate is 145/min, and there is no uterine tenderness. Which nursing action is appropriate?

   • A.Perform a digital cervical examination every 2 hours
   • B.Monitor for infection and assess fetal status
   • C.Encourage tub baths to promote relaxation
   • D.Withhold prescribed antenatal corticosteroids until labor begins

   Answer and rationale are in the full material.