ATI RN
ATI RN Maternal Newborn 2023/24 1st Attempt & Retake Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: B
Rationale: The correct answer is B: Active phase of labor. At 9 cm dilation, the client is transitioning from the latent phase to the active phase. In the active phase, the cervix typically dilates from 6 to 10 cm. The client's contractions are close together and long-lasting, indicating active labor. Rectal pressure is common during the active phase as the baby descends further. The passive descent (
A) phase occurs later in labor when the cervix is fully dilated, and the client is ready to push. Early phase (
C) is characterized by slow cervical dilation from 0 to 6 cm. Descent (
D) phase is not a recognized phase of labor.
Question 2 of 5
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is crucial to prevent umbilical cord compression, maintain blood flow to the fetus, and reduce the risk of hypoxia. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord from further compression and potential infection. Performing a vaginal examination (choice
A) could worsen the situation by causing more cord compression. Administering oxygen (choice
C) is important but covering the cord takes priority. Initiating IV fluids (choice
D) is not the immediate priority in this emergency situation.
Question 3 of 5
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hr. Breastfeeding newborns frequently helps establish milk supply, prevents engorgement, and ensures the baby gets enough nutrients.
Choice A is too limited and may not provide adequate feeding.
Choice B is incorrect as newborns should only be given breast milk or formula, no water.
Choice C is too vague and might not indicate adequate feeding.
Question 4 of 5
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to withdrawal from substances. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and monitoring closely for any signs of seizure activity. Monitoring blood glucose every hour (
A) is unnecessary unless there are specific indications. Placing the infant on his back with legs extended (
B) is not directly related to managing neonatal abstinence syndrome. Providing a stimulating environment (
D) can exacerbate symptoms and should be avoided.
Question 5 of 5
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because assessing the fetal heart rate (FHR) is crucial to ensuring the well-being of the fetus after the client's water has broken. Monitoring the FHR can help detect any signs of distress or complications that may arise. Performing Nitrazine testing (
A) and assessing the fluid (
B) can provide additional information, but monitoring the FHR takes precedence due to its direct impact on fetal well-being. Checking cervical dilation (
C) is important but not as urgent as monitoring the FHR in this situation.