A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?

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ATI Maternal Newborn Proctored Questions

Question 1 of 5

A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Discontinue the infusion of the IV oxytocin. Decelerations starting at the peak of contractions indicate uteroplacental insufficiency, which can be caused by hyperstimulation from oxytocin. Stopping the oxytocin infusion will help alleviate this issue and improve fetal oxygenation. Choice A would not address the underlying cause of the decelerations. Choice C would worsen the hyperstimulation. Choice D is not directly related to the fetal heart rate decelerations.

Question 2 of 5

A client in labor is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

Correct Answer: C

Rationale: The correct answer is C: Contractions that last for 60 seconds each with a 3-minute rest between contractions. In active labor, contractions typically last around 60 seconds each and occur about 2-5 minutes apart. With contractions 4 minutes apart, a 3-minute rest between contractions aligns with the expected pattern. Choice A is incorrect as the rest between contractions is too long. Choice B is incorrect as a contraction lasting 4 minutes is not typical in labor. Choice D is incorrect as the duration of contractions is shorter than expected in active labor. Therefore, Choice C is the most fitting pattern based on the frequency and duration of contractions during labor.

Question 3 of 5

When advising a woman considering pregnancy on nutritional needs to reduce the risk of giving birth to a newborn with a neural tube defect, what information should the nurse include?

Correct Answer: C

Rationale: The correct answer is C: Consume foods fortified with folic acid. Folic acid plays a crucial role in preventing neural tube defects in newborns. It is recommended that women of childbearing age consume 400 mcg of folic acid daily to reduce the risk. Foods fortified with folic acid include cereals, bread, and pasta. A: Limit alcohol consumption - While important for overall health, alcohol consumption is not directly related to preventing neural tube defects. B: Increase intake of iron-rich foods - Iron is essential during pregnancy, but it is not specifically linked to reducing the risk of neural tube defects. D: Avoid foods containing aspartame - Aspartame is a sweetener and does not have a direct impact on neural tube defects prevention.

Question 4 of 5

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

Correct Answer: D

Rationale: The correct answer is D because urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus. This symptom typically improves by the end of the first trimester, as the uterus rises and reduces pressure on the bladder. Therefore, telling the client that it occurs during the first trimester and near the end of pregnancy is accurate. Choice A is incorrect because urinary frequency should not be ignored as it could be a sign of a urinary tract infection or other underlying issue. Choice B is incorrect because it inaccurately suggests that urinary frequency only lasts until the 12th week and implies that poor bladder tone is the sole factor influencing this symptom. Choice C is incorrect because while it is true that individual experiences can vary, there are general patterns and timelines for common pregnancy symptoms like urinary frequency.

Question 5 of 5

A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

Correct Answer: A

Rationale: The correct answer is A: Palpate the client's uterine fundus. Palpating the uterine fundus is crucial to assess for uterine atony, a common cause of postpartum hemorrhage. If the fundus is boggy or deviated, it indicates uterine atony and immediate interventions are needed. B: Assisting the client to a bedpan to urinate is important, but addressing the potential cause of excessive bleeding takes precedence. C: Administering oxytocic medication may be necessary to help stimulate uterine contractions, but assessing the fundus comes first to determine the underlying cause of bleeding. D: Increasing fluid intake is not the priority in this situation. Palpating the fundus and addressing potential hemorrhage are the immediate concerns.

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