A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

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Maternal Newborn ATI Proctored Exam Questions

Question 1 of 9

A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention. A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect. B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect. D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.

Question 2 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 3 of 9

A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

Correct Answer: A

Rationale: The correct answer is A: The client's room number. Using the client's room number as a secondary identifier is not appropriate as it does not uniquely identify the client and can lead to errors. The room number may change, or there could be multiple clients in the same room. Telephone number, birth date, and medical record number are more reliable secondary identifiers as they are unique to the client and less likely to be confused with another individual. It is essential to use accurate and reliable identifiers to ensure patient safety and prevent medication errors.

Question 4 of 9

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 5 of 9

A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?

Correct Answer: A

Rationale: The correct answer is A because using a water-soluble lubricant with condoms can indeed help prevent breakage and maintain effectiveness in preventing pregnancy and STIs. Water-based lubricants are safe to use with condoms as they do not weaken the latex. Option B is incorrect as a diaphragm should be left in place for at least 6 hours after intercourse, not removed after 2 hours. Option C is also incorrect as oral contraceptives are known to improve acne in many cases. Option D is incorrect as a contraceptive patch is typically replaced weekly, not monthly.

Question 6 of 9

A client who is pregnant is scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply)

Correct Answer: D

Rationale: The correct answer is D, All of the Above. 1. Decreased fetal movement indicates fetal distress, necessitating CST. 2. IUGR implies potential placental insufficiency, requiring CST evaluation. 3. Postmaturity increases risk of placental insufficiency, warranting CST. Other choices are incorrect as they do not directly indicate the need for CST in a pregnant client.

Question 7 of 9

A client who received carboprost for postpartum hemorrhage is being assessed by a nurse. Which of the following findings is an adverse effect of this medication?

Correct Answer: A

Rationale: The correct answer is A: Hypertension. Carboprost is a prostaglandin used to treat postpartum hemorrhage that can cause hypertension as an adverse effect due to its vasoconstrictive properties. This can lead to increased blood pressure, which should be monitored closely. Hypothermia (choice B) is not a common adverse effect of carboprost. Constipation (choice C) and muscle weakness (choice D) are also not typically associated with carboprost use. Monitoring blood pressure and signs of hypertension is crucial due to the potential adverse effects of carboprost.

Question 8 of 9

A client who is at 12 weeks of gestation is reviewing a new prescription of ferrous sulfate. Which of the following statements by the client indicates understanding of the teaching?

Correct Answer: C

Rationale: The correct answer is C: "I plan to drink more orange juice while taking this pill." Orange juice is rich in vitamin C, which enhances the absorption of iron from ferrous sulfate, helping to combat iron deficiency anemia during pregnancy. Taking the pill with a vitamin C source is important for optimal absorption. A: Taking the pill with breakfast may not provide enough vitamin C for optimal absorption. B: Milk may inhibit iron absorption due to its calcium content, so it is not ideal to take with ferrous sulfate. D: While increasing calcium-rich foods is important during pregnancy, it is not directly related to enhancing iron absorption from ferrous sulfate.

Question 9 of 9

A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

Correct Answer: D

Rationale: The correct answer is D: Tender lymph nodes. In TORCH infections, which include Toxoplasmosis, Other (syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus, tender lymph nodes are a common finding due to the body's immune response to the infection. Joint pain (choice A) is not typically associated with TORCH infections. Malaise (choice B) is a general feeling of discomfort and is not specific to TORCH infections. Rash (choice C) is also not a common finding in TORCH infections, making it an incorrect choice.

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