ATI OB detailed answer key complete solution with rationale
1. 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, painlessvaginal 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, whichis painful, and the uterus is nonrelaxed or becomes rigid as the
separation advances.
ATI OB detailed answer key
Page 1
,ATI OB detailed answer key complete solution with rationale
C. Abdominal pain with scant red vaginal bleeding
Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence
ofabdominal 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 smallclots 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 menstrualperiod. 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 fundalmassage 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 toprevent uterine atony.
ATI OB detailed answer key
Page 2
,ATI OB detailed answer key complete solution with rationale
3. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is
the prioritynursing action?
A. Administer vitamin K.
Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is
held by themother 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’sabdomen, 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, moreimportant 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."
ATI OB detailed answer key
Page 3
, ATI OB detailed answer key complete solution with rationale
Rationale: This is a nontherapeutic response that disregards the client’s concern and offers
unwarrantedreassurance.
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 duringpregnancy.
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 recursnear the end of the pregnancy as the enlarging uterus places pressure
on the bladder.
ATI OB detailed answer key
Page 4
1. 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, painlessvaginal 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, whichis painful, and the uterus is nonrelaxed or becomes rigid as the
separation advances.
ATI OB detailed answer key
Page 1
,ATI OB detailed answer key complete solution with rationale
C. Abdominal pain with scant red vaginal bleeding
Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence
ofabdominal 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 smallclots 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 menstrualperiod. 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 fundalmassage 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 toprevent uterine atony.
ATI OB detailed answer key
Page 2
,ATI OB detailed answer key complete solution with rationale
3. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is
the prioritynursing action?
A. Administer vitamin K.
Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is
held by themother 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’sabdomen, 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, moreimportant 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."
ATI OB detailed answer key
Page 3
, ATI OB detailed answer key complete solution with rationale
Rationale: This is a nontherapeutic response that disregards the client’s concern and offers
unwarrantedreassurance.
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 duringpregnancy.
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 recursnear the end of the pregnancy as the enlarging uterus places pressure
on the bladder.
ATI OB detailed answer key
Page 4
