The nurse is assessing a client in the second stage of labor. What is the nurse's priority assessment?

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Maternal Newborn ATI Proctored Exam 2023 Questions

Question 1 of 5

The nurse is assessing a client in the second stage of labor. What is the nurse's priority assessment?

Correct Answer: C

Rationale: The correct answer is C: Fetal descent and position. In the second stage of labor, the priority assessment is to monitor fetal descent and position to ensure the baby is progressing through the birth canal correctly. This assessment helps determine if interventions are needed to prevent complications such as fetal distress or prolonged labor. Assessing the frequency of contractions (A) and cervical dilation (B) are important but not the priority in the second stage. Intensity of contractions (D) is also important but not as crucial as monitoring fetal descent and position.

Question 2 of 5

The nurse is caring for a client in the third trimester reporting severe right upper quadrant pain and nausea. What condition should the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: HELLP syndrome. In the third trimester, severe right upper quadrant pain and nausea can indicate HELLP syndrome, a serious pregnancy complication involving hemolysis, elevated liver enzymes, and low platelet count. The pain and nausea are due to liver and gallbladder involvement. Placenta previa typically presents with painless vaginal bleeding, not upper quadrant pain. Hyperemesis gravidarum causes severe nausea and vomiting but not specific upper quadrant pain. Abruptio placentae presents with sudden-onset abdominal pain and vaginal bleeding.

Question 3 of 5

The nurse is assessing a client with hyperemesis gravidarum. What lab finding is most concerning?

Correct Answer: B

Rationale: The correct answer is B: Decreased potassium. In hyperemesis gravidarum, excessive vomiting can lead to electrolyte imbalances, particularly hypokalemia. Potassium plays a crucial role in nerve and muscle function, so a low potassium level can result in serious complications such as cardiac arrhythmias. Elevated hematocrit (A) may indicate dehydration, but it is not as immediately concerning as potassium imbalance. Increased white blood cell count (C) may suggest infection but is not directly related to hyperemesis gravidarum. Low fasting blood glucose (D) can occur due to inadequate nutrient intake but is not the most concerning finding in this case.

Question 4 of 5

The nurse is assessing a client with suspected chorioamnionitis. What is the priority nursing assessment?

Correct Answer: C

Rationale: The correct answer is C: Evaluate fetal heart rate. In chorioamnionitis, fetal distress can occur due to infection and inflammation of the fetal membranes. Monitoring fetal heart rate is crucial to assess the well-being of the baby. Assessing for foul-smelling discharge (A) is important but not the priority. Monitoring maternal blood pressure (B) and checking glucose levels (D) are relevant assessments but do not address the immediate risk of fetal distress in chorioamnionitis.

Question 5 of 5

The nurse is caring for a client in labor with a history of cesarean delivery. What is a priority assessment?

Correct Answer: A

Rationale: The correct answer is A: Assess for signs of uterine rupture. This is the priority assessment because a history of cesarean delivery puts the client at higher risk for uterine rupture during labor. Signs of uterine rupture include severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Early detection and intervention are crucial for the safety of both the mother and the baby. Monitoring maternal temperature (B) is important but not as critical as assessing for uterine rupture. Checking for signs of preeclampsia (C) is also important but not a priority in this specific scenario. Assessing for excessive fetal movement (D) is not a priority assessment in this case.

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