ATI RN
ATI Maternal Newborn Proctored Exam Latest Update Questions
Extract:
Question 1 of 5
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
Correct Answer: B
Rationale: The correct answer is B: "Have you noticed any bloody show or fluid coming from your vagina?" This question helps differentiate true labor from false labor because the presence of bloody show or amniotic fluid suggests cervical changes associated with true labor. Bloody show indicates the shedding of the cervical mucus plug, and amniotic fluid leakage indicates rupture of membranes. This information helps confirm the progression of labor.
Choice A: "When did your contractions begin?" is a general question that does not specifically differentiate between true and false labor.
Choice C: "What happens to your contractions when you move about?" is more related to the management of labor rather than differentiating true labor from false labor.
Choice D: "Have you felt fetal movement over the last 24 hours?" is important for assessing fetal well-being but does not help in distinguishing true labor from false labor.
Question 2 of 5
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. This is accurate information regarding the typical progression of lochia flow postpartum. Lochia rubra is the initial discharge, followed by lochia serosa, and finally, lochia alba. This teaching is important for the client to understand what to expect in terms of postpartum bleeding.
Choice A is incorrect as it inaccurately describes the color changes of lochia.
Choice B is incorrect because the presence of numerous clots is common in the immediate postpartum period and not necessarily abnormal.
Choice C is incorrect as perineal pad saturation is expected initially, and significant saturation may not always indicate hemorrhage.
Question 3 of 5
A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, resulting in fetal hypoxia. This is a sign of fetal distress, as indicated by the repeated drops in fetal heart rate during contractions. Late decelerations occur after the peak of the contraction, reflecting the delayed recovery of the fetal heart rate due to inadequate oxygen supply from the placenta. This prompts the nurse to notify the physician for further evaluation and intervention to address the underlying cause of fetal distress.
Choices A, B, and C are incorrect because they do not accurately describe the characteristics and causes of late decelerations in fetal monitoring.
Question 4 of 5
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
Correct Answer: C
Rationale: The correct answer is C because in an emergency cesarean birth, surgery must be performed quickly to ensure the safety of the mother and baby. Inserting an indwelling catheter is crucial to keep the bladder empty and prevent injury during the incision. This intervention helps maintain a sterile field and reduces the risk of infection. Additionally, a full bladder can impede the progress of surgery. Monitoring O2 saturations and administering pain medications (
A) are postoperative interventions and not relevant in the preoperative phase. Taking vital signs every 15 minutes (
B) is more appropriate for the postoperative period. Assessing breath sounds (
D) is important but typically done by the anesthesiologist during surgery. Instructing the client about breathing exercises (
B) may not be effective in an emergency situation where immediate interventions are necessary.
Question 5 of 5
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
Correct Answer: D
Rationale: The correct answer is D. Giving the newborn a tub bath in two days after circumcision could increase the risk of infection as the circumcision wound needs time to heal. A sponge bath is recommended until the wound is completely healed.
Choice A is correct because yellow exudate is normal during the healing process.
Choice B is correct as keeping the area clean is important.
Choice C is correct as circumcision typically heals within a couple of weeks.