ATI RN
ATI Maternal Newborn Proctored Questions
Question 1 of 5
The nurse is monitoring a client in labor with an epidural. What finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B: Fetal heart rate of 90 beats/minute. A fetal heart rate of 90 bpm indicates fetal distress and requires immediate intervention to prevent potential complications. Decreased fetal heart rate can be a sign of fetal hypoxia or distress. The other choices are not as concerning in this context. A blood pressure of 100/60 mmHg is within normal range. The client reporting warmth in the lower extremities is a common side effect of epidural anesthesia. Contractions every 5 minutes may indicate progress in labor but do not require immediate intervention unless associated with fetal distress.
Question 2 of 5
The nurse is assessing a client in labor with ruptured membranes. What finding indicates the need for immediate intervention?
Correct Answer: C
Rationale: The correct answer is C: Green, foul-smelling fluid. This indicates meconium-stained amniotic fluid, which can be a sign of fetal distress and possible meconium aspiration. Immediate intervention is needed to prevent potential complications for the baby. A: Temperature of 100.6°F could indicate maternal infection but does not require immediate intervention unless other signs are present. B: Clear amniotic fluid is a normal finding. D: Contractions every 5 minutes may indicate active labor, but it is not an immediate concern unless coupled with other signs of distress.
Question 3 of 5
The nurse is reviewing lab results for a pregnant client. Which finding is most concerning?
Correct Answer: C
Rationale: The correct answer is C: Platelet count of 90,000 mm3. A low platelet count (thrombocytopenia) in pregnancy can lead to serious complications like bleeding disorders or preeclampsia. Hemoglobin level of 11 g/dL is within normal range for pregnancy. WBC count of 14,000 mm3 may indicate infection but is not as concerning as thrombocytopenia. Fasting blood glucose of 90 mg/dL is also normal in pregnancy.
Question 4 of 5
The nurse is assessing a client in the third trimester with suspected placental abruption. What finding supports this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Boardlike abdomen and severe pain. This finding supports the diagnosis of placental abruption because it indicates a significant and sudden separation of the placenta from the uterine wall, leading to intense pain and rigidity of the abdomen due to internal bleeding. Painless bright red bleeding (choice A) is more indicative of placenta previa, not placental abruption. A soft, relaxed uterus (choice C) is not typical in placental abruption, which usually presents with uterine tenderness and rigidity. Increased fetal movement (choice D) is not specific to placental abruption and can occur in various pregnancy conditions.
Question 5 of 5
A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.