VATI ATI Comprehensive Predictor 2023 | Nurselytic

Questions 177

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VATI ATI Comprehensive Predictor 2023 Questions

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Question 1 of 5

A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

Correct Answer: C

Rationale: The correct answer is C: Check the FHR. The priority action for the nurse is to assess the fetal heart rate (FHR) to ensure the well-being of the baby. The sudden gush of fluid could indicate rupture of membranes, which may lead to cord prolapse or fetal distress. Monitoring the FHR helps in determining the baby's status and immediate interventions if needed. Performing another internal exam (
A) may increase the risk of infection. Notifying the provider (
B) is important but assessing the baby's well-being comes first. Obtaining a pH test of the fluid (
D) can be done later if needed.

Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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