ATI RN
ATI RN Custom 2023 Fall Exam 3 Questions
Extract:
The client is being rushed into the labor and delivery unit.
Question 1 of 5
At which station would the nurse document the fetus immediately prior to birth? (Enter a numerical value)
Correct Answer: B
Rationale: The nurse would document the fetus immediately prior to birth at station 0. Station 0 corresponds to the level of the ischial spines, indicating the fetus is at the level of the maternal ischial spines and is ready to be born. Station -1 means the fetus is above the ischial spines, not yet engaged in the pelvis. Station 1 indicates the fetus is 1 cm below the ischial spines, not immediately prior to birth. Station 2 indicates the fetus is 2 cm below the ischial spines, also not immediately prior to birth.
Therefore, station 0 is the correct choice for documenting the fetus immediately prior to birth.
Extract:
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently.
Question 2 of 5
Which factor should the nurse identify as a potential cause for urinary frequency?
Correct Answer: D
Rationale: The correct answer is D: Postpartum diuresis. Postpartum diuresis occurs after childbirth due to the body eliminating excess fluid accumulated during pregnancy, leading to increased urine production and urinary frequency. This is a common physiological process in postpartum women.
Choice A, Urinary tract infection, typically presents with symptoms such as burning with urination, urgency, and may be associated with fever.
Choice B, Trauma to pelvic muscles, would more likely present with symptoms like pelvic pain or difficulty with urination.
Choice C, Urinary overflow, is characterized by incomplete bladder emptying leading to dribbling or leakage, rather than increased frequency.
Extract:
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor.
Question 3 of 5
The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
Correct Answer: A
Rationale: The correct answer is A: Variable decelerations. Variable decelerations indicate umbilical cord compression, which can lead to fetal distress. This pattern is characterized by abrupt and transient decreases in the fetal heart rate. Other choices are incorrect because:
B) Early decelerations are associated with head compression during contractions and are considered a normal response to labor;
C) Accelerations are a reassuring sign of fetal well-being, indicating a healthy response to fetal movement;
D) Late decelerations suggest uteroplacental insufficiency, not related to umbilical cord issues.
Extract:
A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions.
Question 4 of 5
Which role do Braxton Hicks contractions play in aiding labor?
Correct Answer: D
Rationale: The correct answer is D. Braxton Hicks contractions help in softening and ripening the cervix. This is essential for labor as a softened and ripened cervix allows for easier dilation, facilitating the baby's passage through the birth canal. Braxton Hicks contractions do not directly affect oxytocin sensitivity (
A), prostaglandin release (
B), or maternal breathing (
C) during labor.
Therefore, the correct answer is D as it directly relates to the physiological process of labor progression.
Extract:
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling 'down' and sad, having no energy, and wanting to cry.
Question 5 of 5
Which of the following is a priority action by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Ask the client if she has considered harming herself or her newborn. This is the priority action because it addresses the immediate safety and well-being of the client and her newborn. By asking about self-harm or harm to the newborn, the nurse can assess for any potential risk and intervene accordingly.
Choices A, B, and C are important actions but do not address the immediate safety concerns. Anticipating a prescription, reinforcing teaching, and identifying coping skills are all valuable tasks, but ensuring the client's safety takes precedence. It is essential to address any potential harm before moving on to other aspects of care.