ATI RN
ATI RN Maternal Newborn Online Practice 2019 B with NGN Questions
Extract:
Client in labor, receiving oxytocin for induction, contractions every 2 min, lasting 90 sec, strong, fetal heart rate 150/min with uniform decelerations
Question 1 of 5
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
Correct Answer: Uniform decelerations (late decelerations) with frequent, strong, prolonged contractions suggest uterine hyperstimulation from oxytocin, requiring discontinuation to prevent fetal distress.
Rationale:
Extract:
Client in labor with external fetal monitor, late decelerations observed
Question 2 of 5
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
Correct Answer: Late decelerations indicate uteroplacental insufficiency, where reduced blood flow to the fetus during contractions causes a drop in fetal heart rate, requiring intervention.
Rationale:
Extract:
Client in labor, provider performs amniotomy
Question 3 of 5
A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?
Correct Answer: Assessing the fetal heart rate is the priority post-amniotomy to detect cord prolapse or compression, ensuring fetal well-being.
Rationale:
Extract:
Client in labor, reports increasing rectal pressure, contractions 2 to 3 min apart, lasting 80 to 90 seconds, cervix dilated to 9 cm
Question 4 of 5
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Correct Answer: The transition phase occurs when the cervix is dilated from 8 to 10 cm, with strong contractions every 2 to 3 minutes, lasting 80 to 90 seconds, and increasing rectal pressure due to fetal descent, as seen with the client's 9 cm dilation.
Rationale:
Extract:
Client in prenatal clinic, Leopold maneuvers show round, firm, moveable part in fundus, long smooth surface on right side
Question 5 of 5
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?
Correct Answer: With the fetal back on the right side, fetal heart tones are best heard in the right upper quadrant, where the fetal chest is closest to the maternal abdomen.
Rationale: