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
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.
Question 3 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 4 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 5 of 9
A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?
Correct Answer: B
Rationale: Correct Answer: B (Respiratory rate 18/min) Rationale: A normal respiratory rate for a newborn is 30-60 breaths/min. A rate of 18/min is below the normal range, indicating potential respiratory distress requiring immediate intervention to ensure adequate oxygenation. Summary of other choices: A: Heart rate 168/min - Normal range for a newborn is 120-160/min. C: Tremors - Common in newborns due to immature nervous system, usually self-resolving. D: Fine crackles - May be present due to residual amniotic fluid and typically resolve without intervention.
Question 6 of 9
A healthcare professional is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the healthcare professional anticipate administering if magnesium sulfate toxicity is suspected?
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. When magnesium sulfate toxicity is suspected, calcium gluconate is administered because it antagonizes the effects of magnesium on the heart and central nervous system. This helps to counteract the muscle weakness, respiratory depression, and cardiac arrhythmias associated with magnesium toxicity. Nifedipine (A) is a calcium channel blocker and is not indicated for magnesium toxicity. Pyridoxine (B) is a form of vitamin B6 and is not used to treat magnesium toxicity. Ferrous sulfate (C) is an iron supplement and is not relevant in the management of magnesium toxicity.
Question 7 of 9
A client at 8 weeks of gestation with iron deficiency anemia is prescribed iron supplements. Which beverage should the nurse reinforce the client to take the supplements with for better absorption?
Correct Answer: D
Rationale: The correct answer is D: Orange juice. Vitamin C enhances iron absorption by converting non-heme iron to a more absorbable form. The acidity in orange juice aids in this process. Ice water (choice A) does not contain any nutrients to enhance iron absorption. Low-fat or whole milk (choice B) contains calcium, which can inhibit iron absorption. Tea or coffee (choice C) contains tannins that can also inhibit iron absorption. In summary, orange juice is the best choice due to its vitamin C content that helps improve iron absorption.
Question 8 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.
Question 9 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.