ATI_Maternity_Proctored_Exam_2021

1. Two idays iafter idelivery, ia ipostpartum iclient iprepares ifor idischarge. iWhat ishould ithe inurse iteach iher iabout ilochia iflow? Incorrect: iLochia idoes ichange icolor ibut igoes ifrom ilochia irubra i(bright ired) ion idays i1-3, ito ilochia iserosa i(pinkish ibrown) ion idays i4-9, ito ilochia ialba i(creamy iwhite) idays i10-21. Incorrect: iNumerous iclots iare iabnormal iand ishould ibe ireported ito ithe iphysician. Incorrect: iSaturation iof ithe iperineal ipad iis iconsidered iabnormal iand imay iindicate ipostpartum ihemorrhage. Correct: iLochia inormally ilasts ifor iabout i21 idays, iand ichanges ifrom ia ibright ired, ito ipinkish ibrown, ito icreamy iwhite. The icolor iof ithe ilochia ichanges ifrom ia ibright ired ito iwhite iafter ifour idays iNumerous ilarge iclots iare inormal ifor ithe inext ithree ito ifour idays Saturation iof ithe iperineal ipad iwith iblood iis iexpected iwhen igetting iup ifrom ithe ibed iLochia ishould ilast ifor iabout i3 iweeks, ichanging icolor ievery ifew idays 2. A inurse imonitors ifetal iwell-being iby imeans iof ian iexternal imonitor. iAt ithe ipeak iof ithe icontractions, ithe ifetal iheart irate ihas irepeatedly idropped i30 ibeats/min ibelow ithe ibaseline. iLate idecelerations iare isuspected iand ithe inurse inotifies ithe iphysician. iWhich iis ithe irationale ifor ithis iaction? Incorrect: iA inuchal icord i(cord iaround ithe ineck) iis iassociated iwith ivariable idecelerations, inot ilate idecelerations. Incorrect: iVariable idecelerations i(not ilate idecelerations) iare iassociated iwith icord icompression. Incorrect: iLate idecelerations iare ia iresult iof ihypoxia. iThey iare inot ireflective iof ithe istrength iof imaternal icontractions. Correct: iLate idecelerations iare iassociated iwith iuteroplacental iinsufficiency iand iare ia isign iof ifetal ihypoxia. iRepeated ilate idecelerations iindicate ifetal idistress. The iumbilical icord iis iwrapped itightly iaround ithe ifetus' ineck The ifetal icord iis ibeing icompressed idue ito irapid idescent iof ithe ifetal ihead iMaternal icontractions iare inot iadequate ienough ito ideliver ithe fetus iThe ifetus iis inot ireceiving iadequate ioxygen iand iis iin distress 3. Which ipreoperative inursing iinterventions ishould ibe iincluded ifor ia iclient iwho iis ischeduled ito ihave ian iemergency icesarean ibirth? Incorrect: iMonitoring iO2 isaturations iand iadministering ipain imedications iare ipostoperative iinterventions. Incorrect: iTaking ivital isigns ievery i15 iminutes iis ia ipostoperative iintervention. iInstructing ithe iclient iregarding ibreathing iexercises iis inot iappropriate iin ia icrisis isituation iwhen ithe iclient's ianxiety iis ihigh, ibecause iinformation iwould iprobably inot ibe iretained. iIn ian iemergency, ithere iis itime ionly ifor iessential iinterventions. Correct: iBecause ithis iis ian iemergency, isurgery imust ibe iperformed iquickly. iAnxiety iof ithe iclient iand ithe ifamily iwill ibe ihigh. iInserting ian iindwelling icatheter ihelps ito ikeep ithe ibladder iempty iand ifree ifrom iinjury iwhen ithe iincision iis imade. Incorrect: iThe inurse ishould ihave iassessed ibreath isounds iupon iadmission. iBreath isounds iare iimportant iif ithe iclient iis ito ireceive igeneral ianesthesia, ibut ithe ianesthesiologist iwill ibe ilistening ito ibreath isounds iin isurgery iin ithat icase. Monitor ioxygen isaturation iand iadminister ipain imedication. Assess ivital isigns ievery i15 iminutes iand iinstruct ithe iclient iabout ipostoperative icare. iAlleviate ianxiety iand iinsert ian iindwelling icatheter. Perform ia isterile ivaginal iexamination iand iassess ibreath isounds. 4. Which inursing iinstruction ishould ibe igiven ito ithe ibreastfeeding imother iregarding icare iof ithe ibreasts iafter idischarge? Incorrect: iEngorgement ioccurs ion iabout ithe ithird ior ifourth ipostpartum iday iand iis ia iresult iof ithe ibreast imilk iformation. iThe iprimary iway ito irelieve iengorgement iis iby ipumping ior ilonger inursing. iGiving ia ibottle iof iformula iwill icompound ithe iproblem ibecause ithe ibaby iwill inot ibe ihungry iand iwill inot iempty ithe ibreasts iwell. Incorrect: iApplying ilotion ito ithe inipples iis inot ieffective ifor ikeeping ithem isoft. iExcessive iamounts iof ilotion imay iharbor imicroorganisms. Correct: iIn iorder ito istimulate iadequate imilk iproduction, ithe ibreasts ishould ibe ipumped iif ithe iinfant iis inot isucking ior ieating iwell, ior iif ithe ibreasts iare inot ifully iemptied. Incorrect: iUsing isoap ion ithe ibreasts idries ithe inipples iand ican icause cracking. iThe ibaby ishould ibe igiven ia ibottle iof iformula iif iengorgement ioccurs. The inipples ishould ibe icovered iwith ilotion iwhen ithe ibaby iis inot inursing. iThe ibreasts ishould ibe ipumped iif ithe ibaby iis inot isucking iadequately. The ibreasts ishould ibe iwashed iwith isoap iand iwater ionce iper iday. 5. A iclient iin ipreterm ilabor iis iadmitted ito ithe ihospital. iWhich iclassification iof idrugs ishould ithe inurse ianticipate iadministering? Correct: iTocolytics iare iused ito istop ilabor. iOne iof ithe imost icommonly iused itocolytic idrugs iis iritodrine i(Yutopar). Incorrect: iAnticonvulsants iare iused ifor iclients iwith ipregnancy-induced ihypertension iwho iare ilikely ito iseize. Incorrect: iThe iglucocorticoids i(e.g., ibetamethasone iand idexamethasone) iare iused ifor iaccelerating ifetal ilung imaturation iand iproduction iof isurfactant. iThey iare icommonly iused iif ithe imembranes iare iruptured ior ilabor icannot ibe istopped. Incorrect: iAnti-infective iare iused iif ithere iis iinfection. iPreterm ilabor imay ior imay inot iinvolve iruptured imembranes iwith iits iaccompanying irisk iof iinfection. Tocolytics iAnticonvulsa ints iGlucocorticoi ids iAnti- iinfective 6. Which iof ithe ifollowing iare iprobable isigns, istrongly iindicating ipregnancy? Incorrect: iThe ipresence iof ifetal iheart isounds iis ia ipositive isign iof ipregnancy; iquickening iis ia ipresumptive iSign iof ipregnancy. Incorrect: iThese iare ipresumptive isigns. iThey imay iindicate ipregnancy ior ithey imay ibe icaused iby iother iconditions, isuch ias idisease iprocesses. Correct: iThese iare iprobable isigns ithat istrongly iindicate ipregnancy. iHegar’s isign iis ia isoftening iof ithe ilower iuterine isegment, iand iChadwick's isign iis ithe ibluish ior ipurplish icolor iof ithe icervix ias ia iresult iof ithe iincreased iblood isupply iand iincreased iestrogen. iBallottement ioccurs iwhen ithe icervix iis itapped iby ian iexaminer's ifinger iand ithe ifetus ifloats iupward iin ithe iamniotic ifluid iand ithen ifalls idownward. Incorrect: iThese iare ipresumptive isigns ithat imight iindicate ipregnancy, ibut ithey imight ibe icaused iby iother iconditions, isuch ias idisease iprocesses. Presence iof ifetal iheart isounds iand iquickening iMissed imenstrual iperiods, inausea, iand ivomiting iHegar's isign, iChadwick's isign, iand iballottement iIncreased iurination iand itenderness iof ithe ibreasts