BRAND NEW ATI PEDIATRICS UNIT DETAILED ANSWER KEY
1. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra a... [Show More] nd several small
clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions
should the nurse take?
A. Document the findings and continue to monitor the client.
Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and
associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual
period. Small clots are common. The nurse should document the findings and continue to
monitor the client.
B. Notify the client’s provider.
Rationale: These are expected findings, so there is no need to notify the provider.
C. Increase the frequency of fundal massage.
Rationale:These are expected findings and the fundus is already firm. Increasing the frequency of fundal
Page 2
massage is not indicated at this time.
D. Encourage the client to empty her bladder.
Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated,
this would be an indication of a distended bladder and the client should be encouraged to void to
prevent uterine atony.
2.A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which ofthe
following findings support this diagnosis?
A. Painless red vaginal bleeding
Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the
uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless
vaginal bleeding occurs in the second and third trimester.
B. Increasing abdominal pain with a nonrelaxed uterus
Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before
delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which
is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances.
C. Abdominal pain with scant red vaginal bleeding
Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of
abdominal pain.
D. Intermittent abdominal pain following passage of bloody mucus
Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor.
The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to
as the "bloody show."
3.A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the
prioritynursing action?
C. Administer vitamin K.
Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is held by the
mother and is breastfed. There is another, more important nursing action.
D. Dry the skin.
Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s
abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn
responds to the cooler environment by increasing his respiratory rate, which can lead to
respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing
action after securing the airway.
E. Administer eye prophylaxis.
Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another,
more important nursing action.
F. Place an identification bracelet.
Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is
completed prior to the mother and newborn leaving the delivery room. There is another, more
important nursing action.
4. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary
frequencyand asks if this will continue until delivery. Which of the following responses should the nurse make?
a. "It's a minor inconvenience, which you should ignore."
Rationale: This is a nontherapeutic response that disregards the client’s concern and offers unwarranted
reassurance.
b. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."
Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during
pregnancy.
c. "There is no way to predict how long it will last in each individual client."
Rationale: This is a nontherapeutic response that does not provide appropriate information to the client.
d. "It occurs during the first trimester and near the end of the pregnancy."
Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs
near the end of the pregnancy as the enlarging uterus places pressure on the bladder.
5. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the
nursenotices she does not have immunity to rubella. Which of the following times should the nurse understand is
recommended for rubella immunization?
a. Shortly after giving birth
Rationale: The rubella immunization should be offered to the client following birth, preferably prior to
discharge from the hospital. This prevents the client from contracting rubella during the current
or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.
b. In the third trimester
Rationale: Because the rubella vaccine contains a live virus, immunizing the client at this point in
pregnancy would put her fetus at risk for developing rubella syndrome.
c. Immediately
Rationale: Because the rubella vaccine contains a live virus, immunizing the client during the first trimester
would put the fetus at risk for developing a severe manifestations of rubella syndrome.
d. During her next attempt to get pregnant
Rationale: Rubella immunization must be given at least 28 days prior to pregnancy to assure that the
developing fetus is not exposed to the virus and put at risk for rubella syndrome.
1. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small
clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions
should the nurse take?
A. Document the findings and continue to monitor the client.
Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and
associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual
period. Small clots are common. The nurse should document the findings and continue to
monitor the client.
B. Notify the client’s provider.
Rationale: These are expected findings, so there is no need to notify the provider.
C. Increase the frequency of fundal massage.
Rationale:These are expected findings and the fundus is already firm. Increasing the frequency of fundal
Page 2
massage is not indicated at this time.
D. Encourage the client to empty her bladder.
Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated,
this would be an indication of a distended bladder and the client should be encouraged to void to
prevent uterine atony.
2.A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which ofthe
following findings support this diagnosis?
A. Painless red vaginal bleeding
Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the
uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless
vaginal bleeding occurs in the second and third trimester.
B. Increasing abdominal pain with a nonrelaxed uterus
Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before
delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which
is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances.
C. Abdominal pain with scant red vaginal bleeding
Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of
abdominal pain.
D. Intermittent abdominal pain following passage of bloody mucus
Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor.
The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to
as the "bloody show."
3.A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the
prioritynursing action?
C. Administer vitamin K.
Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is held by the
mother and is breastfed. There is another, more important nursing action.
D. Dry the skin.
Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s
abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn
responds to the cooler environment by increasing his respiratory rate, which can lead to
respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing
action after securing the airway.
E. Administer eye prophylaxis.
Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another,
more important nursing action.
F. Place an identification bracelet.
Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is
completed prior to the mother and newborn leaving the delivery room. There is another, more
important nursing action.
4. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary
frequencyand asks if this will continue until delivery. Which of the following responses should the nurse make?
a. "It's a minor inconvenience, which you should ignore."
Rationale: This is a nontherapeutic response that disregards the client’s concern and offers unwarranted
reassurance.
b. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."
Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during
pregnancy.
c. "There is no way to predict how long it will last in each individual client."
Rationale: This is a nontherapeutic response that does not provide appropriate information to the client.
d. "It occurs during the first trimester and near the end of the pregnancy."
Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs
near the end of the pregnancy as the enlarging uterus places pressure on the bladder.
5. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the
nursenotices she does not have immunity to rubella. Which of the following times should the nurse understand is
recommended for rubella immunization?
a. Shortly after giving birth
Rationale: The rubella immunization should be offered to the client following birth, preferably prior to
discharge from the hospital. This prevents the client from contracting rubella during the current
or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.
b. In the third trimester
Rationale: Because the rubella vaccine contains a live virus, immunizing the client at this point in
pregnancy would put her fetus at risk for developing rubella syndrome.
c. Immediately
Rationale: Because the rubella vaccine contains a live virus, immunizing the client during the first trimester
would put the fetus at risk for developing a severe manifestations of rubella syndrome.
d. During her next attempt to get pregnant
Rationale: Rubella immunization must be given at least 28 days prior to pregnancy to assure that the
developing fetus is not exposed to the virus and put at risk for rubella syndrome. [Show Less]
