ATI RN
ATI Nur 232 Maternity Final Exam SP24 Questions
Extract:
Medical History: Gravida: 2, Para: 1, Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant, Client has no outstanding medical, social, or surgical history, Plan is to induce labor using oxytocin. Nurse's Notes at 0700 hrs: Client is resting in bed, appears anxious about the induction process. Reports mild, irregular contractions, stating they began around midnight. Fetal heart rate (FHR) is 140 beats per minute, with moderate variability. Cervix is 2 cm dilated, 50% effaced, and the fetal head is at -2 station. Client's partner is present and providing support. IV line is in place, and oxytocin infusion is started at 2 mU/min. Client is encouraged to ambulate as tolerated. Nurse's Notes at 0900 hrs: Client reports increased intensity and frequency of contractions, now occurring every 3-4 minutes. FHR is 145 beats per minute, with moderate variability and occasional accelerations. Cervix is now 4 cm dilated, 70% effaced, and the fetal head is at -1 station. Client is experiencing back pain and requests pain relief. IV oxytocin infusion is increased to 6 mU/min as per protocol. Client is repositioned to a side-lying position for comfort. Partner continues to provide support and encouragement. Vital Signs at 0700 hrs: Temperature: 37.2°C (99°F), Blood Pressure: 120/80 mmHg, Heart Rate: 82 beats per minute, Respiratory Rate: 18 breaths per minute. Vital Signs at 0900 hrs: Temperature: 37.5°C (99.5°F), Blood Pressure: 122/78 mmHg, Heart Rate: 88 beats per minute, Respiratory Rate: 20 breaths per minute. Diagnostic Results at 0900 hrs: Fetal scalp pH: 7.25, Amniotic fluid: Clear, no meconium present. A nurse is caring for a client who is 42 weeks of gestation.
Question 1 of 5
Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.
| Action | anticipated | nonessential | contraindicated |
|---|---|---|---|
| Increase the oxytocin infusion to 13 mU/min | |||
| Place client in a side-lying position | |||
| Initiate bolus of primary IV fluids | |||
| Apply oxygen at 10 L/min via venturi mask | |||
| Perform sterile vaginal exam | |||
| Assign a Bishop score | |||
| Perform an amniotomy |
Correct Answer: A: Anticipated, B: Anticipated, C: Anticipated, D: Nonessential, E: Anticipated, F: Nonessential, G: Nonessential
Rationale: Increasing the oxytocin infusion to 13 mU/min is anticipated as contractions are progressing and cervical dilation is increasing. Placing the client in a side-lying position is anticipated to improve circulation and alleviate back pain. Initiating a bolus of IV fluids is anticipated to prevent dehydration during labor. Applying oxygen is nonessential as there are no signs of respiratory distress. Performing a sterile vaginal exam is anticipated to monitor labor progression. Assigning a Bishop score is nonessential since labor is already progressing. Performing an amniotomy is nonessential as labor is progressing normally without intervention.
Extract:
A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus.
Question 2 of 5
What information should the nurse give to the client?
Correct Answer: A, E
Rationale: A cesarean section prevents neonatal herpes transmission if lesions are present at labor. Valacyclovir suppressive therapy after 36 weeks reduces outbreak risk.
Extract:
A nurse in the newborn unit is caring for several infants.
Question 3 of 5
Which of the following situations requires the nurse's immediate attention and intervention?
Correct Answer: D
Rationale: Not passing meconium within 24 hours may indicate a bowel obstruction like meconium ileus, requiring immediate attention. Not voiding within 24 hours, acrocyanosis, and a temperature of 37.5°C are typically normal or less urgent findings.
Extract:
What is important for a woman to understand before undergoing a scheduled tubal ligation?
Question 4 of 5
She should schedule it to be done just before a menstrual flow
Correct Answer: D
Rationale: Tubal ligation should be considered irreversible due to the low success rate of reversal procedures.
Extract:
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole.
Question 5 of 5
Which of the following findings should the nurse expect to observe in this client?
Correct Answer: A
Rationale: Excessive uterine enlargement is expected in hydatidiform mole due to trophoblastic overgrowth.