A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?

Questions 98

ATI LPN

ATI LPN Test Bank

Maternal Newborn ATI Proctored Exam Questions

Question 1 of 9

A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?

Correct Answer: A

Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress. Summary of other choices: B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring. C: Inserting an IV catheter is important but not the priority when late decelerations are observed. D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.

Question 2 of 9

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?

Correct Answer: C

Rationale: The correct answer is C: Obtain a gift from the newborn to present to the sibling. This suggestion helps foster acceptance and bonding between the siblings by creating a positive association and sense of reciprocity. It allows the 7-year-old to feel included and appreciated in the new family dynamic. Explanation of why the other choices are incorrect: A: Allowing the sibling to hold the newborn during a bath may not be safe or appropriate, and could potentially lead to accidents or discomfort for the newborn. B: Forcing physical affection like kissing may not be well-received by the sibling and could create negative feelings towards the newborn. D: Switching the sibling's room with the nursery could disrupt the sibling's sense of stability and security, potentially causing confusion and anxiety.

Question 3 of 9

A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?

Correct Answer: B

Rationale: Rationale: Massaging the client's fundus helps to stimulate uterine contractions and control postpartum hemorrhage caused by uterine hypotonicity. This action helps prevent further blood loss and promotes uterine tone. Checking capillary refill would not directly address the immediate issue of hemorrhage. Inserting a urinary catheter is not a priority in managing postpartum hemorrhage. Preparing for a blood transfusion may be necessary later, but addressing the uterine hypotonicity and hemorrhage is the priority.

Question 4 of 9

A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?

Correct Answer: A

Rationale: The correct answer is A: Dark green leafy vegetables. Dark green leafy vegetables like kale, spinach, and broccoli are excellent sources of calcium. They provide a good alternative to dairy for those who don't like milk. These vegetables are rich in calcium, which is essential for bone health, especially during pregnancy. They also offer other nutrients like vitamin K and magnesium that support calcium absorption. Summary: B: Deep red or orange vegetables - While these vegetables are nutritious, they are not significant sources of calcium. C: White bread and rice - These foods do not provide a significant amount of calcium. D: Meat, poultry, and fish - While these foods are rich in protein and other nutrients, they are not primary sources of calcium.

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 at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?

Correct Answer: B

Rationale: Rationale for Correct Answer B: It is normal to have these feelings during the first few months of pregnancy. 1. Acknowledges client's emotions without judgment. 2. Validates the client's experience as common and normal. 3. Provides reassurance and support. 4. Encourages open communication. Summary of Incorrect Choices: A. Not necessary to escalate without client's consent. C. Invalidates client's feelings and imposes expectations. D. Implies assumption of severity and may be seen as intrusive.

Question 7 of 9

A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?

Correct Answer: C

Rationale: The correct answer is C: Petechiae over the head. This is because tight nuchal cord can cause pressure on the baby's head during delivery, leading to tiny red or purple spots called petechiae due to capillary rupture. Bruising over the buttocks (A) is more common in breech deliveries, hard nodules on the roof of the mouth (B) could indicate Epstein pearls which are benign and common in newborns, and bilateral periauricular papillomas (D) are not related to nuchal cord compression.

Question 8 of 9

During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?

Correct Answer: D

Rationale: The correct answer is D: Decreased urine output. At 26 weeks of gestation, decreased urine output can be a sign of potential complications like preeclampsia or dehydration, which require immediate medical attention to prevent harm to the mother and baby. Leukorrhea (choice A) is a common pregnancy symptom and not typically concerning. Supine hypotension (choice B) is a known issue in pregnancy but usually occurs later in the third trimester due to pressure on the vena cava when lying on the back. Periodic numbness of the fingers (choice C) can be related to carpal tunnel syndrome, which is common in pregnancy but not typically urgent at 26 weeks unless severe and persistent.

Question 9 of 9

A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)

Correct Answer: D

Rationale: The correct answer is D: All of the above. At 6 weeks of gestation, common discomforts include breast tenderness due to hormonal changes, urinary frequency from increased blood flow to kidneys, and epistaxis (nosebleeds) due to increased blood volume and vessel fragility. Therefore, all options are relevant and should be included in the education. Other choices are incorrect because they do not encompass all the common discomforts experienced during early pregnancy.

Access More Questions!

ATI LPN Basic


$89/ 30 days

ATI LPN Premium


$150/ 90 days