ATI RN
RN ATI Maternal Newborn 2023 with NGN 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: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates the baby is descending into the birth canal. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage. Passive descent (choice
A) refers to the initial descent of the baby before the active pushing stage. Active (choice
B) and early (choice
C) phases are terms used for the first stage of labor, not the second stage. The client's dilation and symptoms clearly indicate they are in the descent phase of the second stage of labor.
Question 2 of 5
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: You should press the handheld button when you feel your baby move.
Rationale:
1. Nonstress test monitors fetal heart rate in response to fetal movement.
2. Pressing the handheld button when feeling baby move allows correlation of fetal heart rate changes with movements.
3. This action helps assess the well-being of the fetus and indicates a reactive nonstress test.
4. It is essential for the nurse to educate the client on this key step for accurate test results.
Summary:
A: Incorrect. The test duration is not related to this specific instruction.
B: Incorrect. Lying in a supine position may affect blood flow and should be avoided.
C: Incorrect. Fasting is not necessary for a nonstress test.
Question 3 of 5
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common indicator of pain in newborns as they are unable to verbally express discomfort. It is a physical sign of distress often observed during painful procedures like circumcision. Decreased heart rate (choice
A), pinpoint pupils (choice
C), and slowed respirations (choice
D) are not specific indicators of pain in newborns and can be influenced by various factors. In contrast, chin quivering is a more reliable and direct sign of pain in this context.
Question 4 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: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates the baby is descending into the birth canal. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage. Passive descent (choice
A) refers to the initial descent of the baby before the active pushing stage. Active (choice
B) and early (choice
C) phases are terms used for the first stage of labor, not the second stage. The client's dilation and symptoms clearly indicate they are in the descent phase of the second stage of labor.
Question 5 of 5
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: B, C, D, A
Rationale: The correct sequence for performing Leopold maneuvers is B, C, D, A. First, palpate the fundus to identify the fetal part (
B). Next, determine the location of the fetal back (
C).
Then, palpate for the fetal part presenting at the inlet (
D). Finally, identify the attitude of the head (
A). This sequence allows for a systematic assessment of the fetus's position in the uterus, starting from identifying the fetal part and progressing to determining the position and attitude.
Choices E, F, and G are not relevant to the sequential steps of Leopold maneuvers and do not contribute to the proper assessment of fetal presentation.