ATI LPN
Maternal Newborn ATI Proctored Exam Questions
Question 1 of 5
A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.
Question 2 of 5
A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)
Correct Answer: A
Rationale: Rationale: A client at 42 weeks of gestation is at risk for oligohydramnios, which is associated with decreased amniotic fluid levels. Amnioinfusion can be used to increase amniotic fluid volume to prevent fetal cord compression and facilitate fetal movement during labor. Summary: - B: Hydramnios (excessive amniotic fluid) does not require amnioinfusion. - C: Fetal cord compression is a reason for amnioinfusion, not a condition to prepare for. - D: Polyhydramnios (excessive amniotic fluid) does not typically require amnioinfusion unless there are complicating factors.
Question 3 of 5
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
Question 4 of 5
When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?
Correct Answer: C
Rationale: The correct answer is C because counting the fetal heart rate after a contraction helps determine baseline changes, which is essential for identifying fetal distress. This method allows for accurate assessment of fetal well-being in response to contractions. Choice A is incorrect as 15 seconds is not enough time to establish a baseline. Choice B is incorrect as auscultating every 5 minutes may not provide timely information during the active phase. Choice D is incorrect because auscultating every 30 minutes in the second stage may miss important changes in fetal status. Therefore, option C is the most appropriate choice for intermittent fetal heart monitoring.
Question 5 of 5
During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?
Correct Answer: A
Rationale: The correct answer is A: Maternal fever. Maternal fever can lead to tachycardia in the fetus due to the transfer of maternal antibodies, cytokines, and other inflammatory mediators across the placenta, affecting fetal heart rate. Maternal fever can indicate infection, which can cause fetal distress. The other choices are incorrect because: B: Fetal heart failure typically presents with bradycardia, not tachycardia. C: Maternal hypoglycemia can affect the fetus but is more likely to cause fetal bradycardia than tachycardia. D: Fetal head compression can result in decelerations but not necessarily tachycardia.