ATI OB DETAILED ANSWER KEY
1. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?
A. Painless red vaginal bleeding
Rationale: Placenta previa is a condition of pregnancy when the placenta ...
ATI Detailed Answer Key medical OB Created on:11/29/2018Page 1ATI OB DETAILED ANSWER KEY
1.A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the 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."
2.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 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. ATI Detailed Answer Key medical OB Created on:11/29/2018Page 23.A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?
A.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.
B.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.
C.Administer eye prophylaxis.
Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another, more important nursing action.
D.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 frequency and 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. ATI Detailed Answer Key medical OB Created on:11/29/2018Page 35.A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood
work, the nurse notices 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.
6.A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?
A.Clear the respiratory tract.
Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following delivery.
B.Dry the infant off and cover the head.
Rationale: Drying the infant and covering the head should be done shortly after the delivery, but it is not the first action the nurse should take.
C.Stimulate the infant to cry.
Rationale: Stimulating the infant to cry should be done shortly after the delivery, but it is not the first action the nurse should take.
D.Cut the umbilical cord.
Rationale: Cutting the umbilical cord should be done shortly after the delivery, but it is not the
first action the nurse should take.
7.A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? ATI Detailed Answer Key medical OB Created on:11/29/2018Page 4A."What part of the exam makes you most nervous?"
Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns.
B."Don't worry, I will be with you during the exam."
Rationale: This closed-ended nontherapeutic response discounts the client's feelings and does not encourage further discussion.
C."All you need to do is relax."
Rationale: This closed-ended nontherapeutic response does not address the client's concerns and does not encourage further discussion. It blocks communication by using a cliché and false reassurance.
D."A pelvic exam is required if you want birth control pills."
Rationale: This statement fails to address the client’s feelings that she shared with the nurse. It blocks communication and does not encourage further discussion.
8.A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse
examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
A.Two veins and one artery
Rationale: This is not the correct combination of vessels.
B.One artery and one vein
Rationale: This is not the correct combination of vessels.
C.Two arteries and one vein
Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta.
D.Two arteries and two veins
Rationale: This is not the correct combination of vessels.
9.A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable?
A.A male condom
Rationale: This method of contraception has 11 to 16 failures for every 100 users.
B.An intrauterine device (IUD)
Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most
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