ATI LPN
Maternal Newborn ATI Proctored Exam Questions
Question 1 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 2 of 9
When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?
Correct Answer: A
Rationale: The correct answer is A: Vaginal bleeding. This is crucial to report promptly as it could indicate serious issues like placental abruption or miscarriage. Swelling of the ankles (B) is common in pregnancy but not typically an urgent concern. Heartburn (C) is common and can be managed with lifestyle changes. Lightheadedness when lying on the back (D) is likely due to inferior vena cava compression and can be relieved by changing position. Reporting vaginal bleeding is vital for timely intervention in pregnancy complications.
Question 3 of 9
A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?
Correct Answer: C
Rationale: The correct answer is C: Attention-focusing. At 40 weeks gestation with a platelet count of 75,000/mm3, epidural analgesia is contraindicated due to the risk of epidural hematoma. Naloxone hydrochloride is an opioid antagonist used for opioid overdose, not for labor pain relief. Pudendal nerve block is used for local anesthesia during the second stage of labor, not for early labor pain relief. Attention-focusing techniques can help the client manage pain without pharmacological interventions, ensuring safety for both the client and the baby.
Question 4 of 9
When a client states, 'My water just broke,' what is the nurse's priority intervention?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) helps determine the well-being of the baby after the water breaking. Monitoring the FHR can indicate if the baby is in distress and prompt further actions if needed. Performing Nitrazine testing (choice A) is used to confirm if the fluid is amniotic fluid, but FHR monitoring takes precedence. Assessing the fluid (choice B) is important but not as urgent as monitoring the FHR. Checking cervical dilation (choice C) is not the priority as ensuring the baby's well-being through FHR monitoring is crucial in this situation.
Question 5 of 9
A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother. A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.
Question 6 of 9
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, 'I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device.' The nurse should suspect which of the following?
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. Given the client's symptoms of right-sided lower quadrant abdominal pain, vaginal bleeding, missed menstrual cycle, and presence of an intrauterine device, these are classic signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, commonly in the fallopian tube, leading to abdominal pain and vaginal bleeding. The other choices are incorrect because: A: Missed abortion would typically present with cramping, bleeding, and passage of tissue. C: Severe preeclampsia is characterized by high blood pressure and proteinuria, not the symptoms described. D: Hydatidiform mole would typically present with vaginal bleeding and uterine enlargement, but not the sharp abdominal pain described.
Question 7 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 8 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 9 of 9
An adolescent is being taught about levonorgestrel contraception by a school nurse. What information should the nurse include in the teaching?
Correct Answer: A
Rationale: Step 1: Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours after unprotected sex. Step 2: Taking the medication within the specified time frame increases its effectiveness in preventing pregnancy. Step 3: Thus, the nurse should emphasize to the adolescent the importance of taking the medication promptly after unprotected intercourse. Step 4: This information is crucial for the adolescent to understand the time-sensitive nature of levonorgestrel contraception. Summary: - Choice B is incorrect because it provides contradictory information. Levonorgestrel can be taken even if the individual is on an oral contraceptive. - Choice C is incorrect as starting a period is not a reliable indicator of pregnancy. A pregnancy test is recommended if there are concerns. - Choice D is incorrect because levonorgestrel is a single-dose emergency contraception and does not provide protection for 14 days.