2024 RN ATI Maternal Newborn 2019 with NGN
Updated 2024-2025 with All Questions, Answers
and Rationale
Question 1:
After completing post anesthesia
... [Show More] recovery assessments, the registered nurse
(RN) asks the practical nurse (PN) to transfer four clients, each two hours postbirth, to the postpartum unit. Which client should the PN ask the RN to reassess
prior to transfer?
A. A primigravida whose perineal pain has worsened one hour after being
medicated.
B. A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one
hour.
C. A multigravida complaining of strong afterbirth pains when breastfeeding.
D. A primigravida who passed a small clot when she sat up on the edge of the
bed
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Explanation
This client should be reassessed by the RN prior to transfer, as worsening perineal
pain may indicate a hematoma, infection, or inadequate pain management. The
RN should inspect the perineum, check the vital signs, and evaluate the
effectiveness of the medication.
The other options are not correct because:
B .A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour
does not need to be reassessed by the RN, as this is a normal finding for a client
two hours post-birth. Lochia rubra is the red-colored vaginal discharge that
contains blood and debris from the placental site, and it usually lasts for 3 to 4
days after delivery. A peri-pad that is 1/4 saturated after one hour is within the
expected range of blood loss.
C. A multigravida complaining of strong afterbirth pains when breastfeeding
does not need to be reassessed by the RN, as this is a normal finding for a client
two hours post-birth. Afterbirth pains are cramps caused by uterine contractions
that help shrink the uterus and prevent bleeding. They are more common and
intense in multiparous women and during breastfeeding, as oxytocin is released
and stimulates the contractions.
D. A primigravida who passed a small clot when she sat up on the edge of the
bed does not need to be reassessed by the RN, as this is a normal finding for a
client two hours post-birth. Small clots may form in the uterus or vagina due to
pooling of blood during rest or anesthesia, and they are usually expelled when
changing position or ambulating. As long as the clot is smaller than a plum and
there is no excessive bleeding or pain, it is not a cause for concern.
Question 2:
A nurse is discussing risk factors of postpartum hemorrhage with a newly
licensed nurse.
Which of the following conditions is a risk factor for postpartum hemorrhage
that the nurse should include in the teaching?
A. Pregnancy induced hypertension.
B. Meconium stained fluid.
C. Retained placental fragments.
D. Oligohydramnios.
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Explanation
Retained placental fragments is a risk factor for postpartum hemorrhage. After
delivery, the uterus continues to contract to deliver the placenta.
Contractions also help to compress the blood vessels where the placenta was
atached to the uterine wall.
Postpartum hemorrhage can happen if parts of the placenta stay atached to the
uterine wall.
Choice A is incorrect because pregnancy-induced hypertension is a risk factor
for
postpartum hemorrhage.
Choice B is incorrect because meconium-stained fluid is not mentioned as a risk
factor for postpartum hemorrhage in my sources.
Choice D is incorrect because oligohydramnios is not mentioned as a risk factor
for postpartum hemorrhage in my sources.
Question 3:
A nurse is planning care for a client who is pregnant and has HIV.
Which of the following actions should the nurse include in the plan of care?
A. Use a fetal scalp electrode during labor and delivery.
B. Bathe the newborn before initiating skin-to-skin contact.
C. Instruct the client to stop taking the antiretroviral medications at 32 weeks of
gestation.
D. Administer a pneumococcal immunization to the newborn within 4 hours
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