ATI LPN
Maternal Newborn ATI Proctored Exam Questions
Question 1 of 9
A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?
Correct Answer: C
Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.
Question 2 of 9
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
Correct Answer: C
Rationale: The correct answer is C: Monitor the FHR continuously. This is essential in preeclampsia as magnesium sulfate can affect fetal heart rate (FHR). Continuous monitoring helps detect any changes promptly. A: Monitoring blood pressure is important but not as critical as FHR monitoring in this scenario. B: Restricting total hourly intake to 200 mL is not necessary for magnesium sulfate administration. D: Administering protamine sulfate is incorrect as it is used for heparin toxicity, not magnesium sulfate toxicity.
Question 3 of 9
A caregiver is learning about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because dressing the baby in flame-retardant clothing is a safety measure to reduce the risk of burns. Flame-retardant clothing can help protect the baby in case of accidental exposure to fire or heat sources. Choice B is incorrect because putting a bib on the baby at night can pose a suffocation hazard. Choice C is incorrect because warming formula in the microwave can create hot spots that may burn the baby's mouth. Choice D is incorrect because covering the crib mattress with plastic can increase the risk of suffocation and overheating for the baby.
Question 4 of 9
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 5 of 9
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 6 of 9
A healthcare professional is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition?
Correct Answer: D
Rationale: The correct answer is D: Report of severe shoulder pain. In a ruptured ectopic pregnancy, the fertilized egg implants outside the uterus, usually in the fallopian tube. As the tube ruptures, there is internal bleeding which can irritate the diaphragm, causing referred pain to the shoulder. This phenomenon is known as Kehr's sign. The other choices are incorrect because with a ruptured ectopic pregnancy, there would typically be altered menses due to the pregnancy disruption, a transvaginal ultrasound would not show a fetus in the uterus, and blood progesterone levels would not be elevated.
Question 7 of 9
A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems. A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes. B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being. C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.
Question 8 of 9
A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Eat crackers or plain toast before getting out of bed. This recommendation helps alleviate morning sickness by providing a small, easily digestible snack to settle the stomach before getting up. It helps stabilize blood sugar levels and prevent an empty stomach exacerbating nausea. Explanation for why B, C, and D are incorrect: B: Awakening during the night to eat a snack can disrupt sleep patterns and is not necessary for managing morning sickness. C: Skipping breakfast and waiting until lunch may lead to prolonged nausea and low blood sugar levels, worsening symptoms. D: Eating a large evening meal can increase the likelihood of acid reflux and indigestion, making morning sickness worse.
Question 9 of 9
A client in active labor at 39 weeks of gestation is receiving continuous IV oxytocin and has early decelerations in the FHR on the monitor tracing. What action should the nurse take?
Correct Answer: B
Rationale: The correct action for the nurse to take when a client in active labor at 39 weeks of gestation has early decelerations in the FHR on the monitor tracing is to continue monitoring the client. Early decelerations are typically benign and are associated with head compression during contractions, which is a normal response to labor. There is no need to discontinue the oxytocin infusion as early decelerations do not indicate fetal distress. Requesting the provider to assess the client may not be necessary at this point unless other concerning signs are present. Increasing the infusion rate of the maintenance IV fluid is not indicated as it would not address the early decelerations. Therefore, the best course of action is to continue monitoring the client for any changes in the FHR pattern.