The nurse is reviewing lab results for a pregnant client. Which finding is most concerning?

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ATI Maternal Newborn Proctored Questions

Question 1 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 2 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.

Question 3 of 5

The nurse is teaching a client about preterm labor prevention. What instruction is most appropriate?

Correct Answer: A

Rationale: The correct answer is A because adequate hydration helps prevent preterm labor by maintaining amniotic fluid levels and preventing dehydration-induced contractions. Drinking 8-10 glasses of water daily ensures proper hydration. B is incorrect because lying down during the day does not have a direct impact on preterm labor prevention. C is incorrect as excessive physical activity can sometimes trigger preterm labor instead of preventing it. D is incorrect as protein intake is important for fetal development and reducing it can lead to nutritional deficiencies, but it is not a direct factor in preventing preterm labor.

Question 4 of 5

The nurse is monitoring a client during the first stage of labor. What finding requires immediate intervention?

Correct Answer: C

Rationale: The correct answer is C because variable decelerations on the fetal monitor indicate umbilical cord compression, which can lead to fetal distress and hypoxia. Immediate intervention is needed to relieve the compression and prevent potential harm to the baby. Contractions every 3-5 minutes (A) are normal in the first stage of labor. A baseline fetal heart rate of 110 beats/minute (B) is within the normal range for a fetus. Client reporting back pain (D) is a common symptom of labor and not necessarily indicative of a complication requiring immediate intervention.

Question 5 of 5

The nurse is teaching a client about foods rich in folic acid during pregnancy. Which food should the nurse recommend?

Correct Answer: A

Rationale: The correct answer is A, citrus fruits. Folic acid is important for fetal development and helps prevent birth defects. Citrus fruits like oranges, grapefruits, and lemons are rich sources of folic acid. They provide the necessary nutrients for a healthy pregnancy. Lean meats (B) are good sources of protein but not specifically high in folic acid. Dairy products (C) are important for calcium but do not contain significant amounts of folic acid. Whole grains (D) are beneficial for fiber and nutrients, but they are not the best source of folic acid compared to citrus fruits.

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