ATI LPN
ATI Maternal Newborn Proctored Questions
Question 1 of 5
A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
Correct Answer: D
Rationale: The correct answer is D: Assist the client to turn onto her side. This intervention is essential to improve blood flow to the placenta and fetus, thus helping to increase blood pressure and prevent hypotension. Turning the client onto her side can help relieve pressure on the vena cava, allowing for better circulation. A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading. B: Assisting the client to an upright position may worsen hypotension as it can further decrease blood flow to the placenta. C: Preparing for an immediate vaginal delivery is not necessary solely based on the client's blood pressure reading.
Question 2 of 5
When monitoring uterine contractions in a client in the active phase of the first stage of labor, which finding should the nurse report to the provider?
Correct Answer: A
Rationale: Rationale: Contractions lasting longer than 90 seconds can indicate uterine hyperstimulation, which can lead to decreased oxygenation of the fetus. This finding should be reported to the provider for further assessment and intervention. Contractions occurring every 3 to 5 minutes (choice B) are normal in the active phase of labor. Strong contractions (choice C) are also expected during this phase. Feeling contractions in the lower back (choice D) is common and not typically a cause for concern. Reporting contractions lasting longer than 90 seconds is crucial to ensure the safety of both the mother and the baby.
Question 3 of 5
A client who is at 6 weeks of gestation with her first pregnancy asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?
Correct Answer: C
Rationale: The correct answer is C: This will occur between the fourth and fifth months of pregnancy. Quickening typically happens around 18-20 weeks, which falls between the fourth and fifth months of pregnancy. During this time, the fetus's movements become more pronounced and can be felt by the pregnant person. Choices A, B, and D are incorrect because quickening does not occur in the last trimester, end of the first trimester, or when the uterus rises out of the pelvis. These options do not align with the typical timing of quickening in pregnancy.
Question 4 of 5
A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Apply an ice pack to the affected area. Ice helps reduce inflammation and numb the pain, providing relief for the client. Step 1: Ice constricts blood vessels, reducing swelling and pain. Step 2: Ice numbs the area, providing immediate relief. Step 3: Ice is recommended for acute pain management. Summary: B (warm sitz bath) may increase blood flow and exacerbate swelling. C (antiseptic solution) is not indicated for pain relief. D (hot pack) may worsen inflammation and pain.
Question 5 of 5
A client is 1 hour postpartum and the nurse observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Rationale: 1. Lochia rubra and small clots are expected postpartum. 2. The firm, midline fundus indicates normal involution. 3. No signs of excessive bleeding or fundus displacement. 4. Documenting and monitoring is appropriate for normal postpartum assessment. Summary: A: Not necessary as no complications present. B: Unnecessary and could cause discomfort. C: Bladder emptying may help fundal position but not urgent. D: Correct option for normal postpartum assessment and monitoring.