ATI LPN
Maternal Newborn ATI Proctored Exam Questions
Question 1 of 5
A client in active labor is irritable, reports the urge to have a bowel movement, vomits, and states, 'I've had enough. I can't do this anymore.' Which of the following stages of labor is the client experiencing?
Correct Answer: C
Rationale: The client is experiencing the transition phase of labor. This stage occurs between the first and second stages, characterized by intense contractions, rapid cervical dilation, and strong emotions like irritability and feeling overwhelmed. The urge to have a bowel movement and vomiting are common signs indicating the baby is descending. The statement 'I can't do this anymore' is typical of transition as it signifies the peak of discomfort before the urge to push in the second stage. Other options are incorrect as the symptoms described align with the transition phase.
Question 2 of 5
During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?
Correct Answer: C
Rationale: The correct answer is C because it accurately describes an episiotomy as an incision made by the provider to facilitate delivery of the fetus. This information is crucial for the client to understand the purpose and potential benefits of the procedure. A: While choice A is similar to the correct answer, it includes unnecessary detail about who makes the incision, which may confuse the client. B: Choice B is incorrect as it provides inaccurate information about a fourth-degree episiotomy extending into the rectal area, which is not recommended as it would involve cutting through the anal sphincter. D: Choice D is incorrect because it introduces unnecessary information about the types of episiotomies without providing the basic understanding of what an episiotomy is.
Question 3 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 4 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 5 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.