ATI RN
Custom ATI Maternity Exam 2 Questions
Extract:
Client in the first stage of labor with umbilical cord protruding from the vagina
Question 1 of 5
A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?
Correct Answer: Placing the client in a knee-chest or Trendelenburg position is the priority to relieve pressure on the prolapsed cord, restoring blood flow to the fetus and preventing hypoxia. This addresses the immediate risk of cord compression.
Rationale:
Extract:
Client in active labor with late decelerations on fetal monitor tracing
Question 2 of 5
The nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?
Correct Answer: Positioning the client on her side is the first action to take as it reduces compression of the inferior vena cava and aorta, improving maternal and fetal circulation. This addresses the uteroplacental insufficiency causing late decelerations, which indicate fetal hypoxia.
Rationale:
Extract:
Client who is at 39 weeks of gestation
Question 3 of 5
A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?
Correct Answer: A surge of energy, or nesting instinct, is a common sign of impending labor. Weight gain, decreased discharge, or urinary retention are not typical precursors to labor.
Rationale:
Extract:
Client who is postpartum
Question 4 of 5
A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
Correct Answer: A temperature of 100.4°F for two days suggests a possible infection, such as endometritis, requiring immediate attention. The other findings are normal or expected postpartum.
Rationale:
Extract:
Client in labor
Question 5 of 5
A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?
Correct Answer: A fetal heart rate of 100/min for 10 minutes indicates bradycardia, suggesting fetal distress or hypoxia, which requires immediate reporting. The other findings are within normal limits for active labor.
Rationale: