ATI RN
RN Maternal Nursing OB Newborn 2023 2024 Exam Questions
Extract:
A nurse is caring for a client who is in labor.
Exhibit1
Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90
seconds. Client rates pain with contractions as 10 on a scale of 0
to 10 and requests an epidural. Contractions approximately 4
min apart. Vaginal examination reveals cervix dilated 5 cm. 80%
effaced, -1 station, vertex presentation. FHR baseline 142/min
with moderate variability. IV fluid bolus initiated.
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on
a scale of 0 to 10.
0950.
Spontaneous rupture of membranes with clear fluid
1000:
Variable decelerations noted on the electronic fetal heart rate
monitor tracing, FHR baseline 140/min. Deceleration 90/min,
lasting 30 seconds. Loop of umbilical cord visible at vaginal introitus
Question 1 of 5
Select the 5 actions the nurse should take
Correct Answer: A,B,C,D,F
Rationale: A prolapsed umbilical cord is a life-threatening emergency requiring immediate intervention to relieve cord compression and restore fetal oxygenation. The priority actions are:
Notify the provider
Reposition the client (Trendelenburg or knee-chest)
Manually relieve pressure on the cord
Administer oxygen
Increase IV fluids for better circulation
Extract:
Question 2 of 5
What is the function of the placenta during pregnancy?
Correct Answer: D
Rationale: The placenta serves multiple functions, including transporting oxygen and nutrients, removing waste products, and helping regulate fetal temperature.
Question 3 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: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. During this phase, contractions are strong and frequent, leading to rapid cervical dilation. The increasing rectal pressure and close contractions indicate active labor.
Choice A: Passive descent - Incorrect. This phase occurs after full dilation and is characterized by fetal descent.
Choice C: Early phase - Incorrect. This phase occurs at the beginning of labor when the cervix is dilating from 0 to 3 cm.
Choice D: Descent - Incorrect. Descent refers to the movement of the fetus through the birth canal, not a specific phase of labor.
Question 4 of 5
What is the recommended method of screening for gestational diabetes during pregnancy?
Correct Answer: C
Rationale: The oral glucose tolerance test (OGTT) is the standard method for screening gestational diabetes during pregnancy.
Question 5 of 5
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. After a vaginal birth, the uterus should be midline and firm. Palpating the uterus to the right above the umbilicus indicates a full bladder displacing the uterus. A distended bladder can prevent the uterus from contracting properly, leading to postpartum hemorrhage. By assisting the client to empty their bladder, the nurse helps the uterus contract effectively, reducing the risk of complications. Options A and B are incorrect as they do not address the underlying issue of a full bladder. Option D is incorrect as lying on the right side does not address the bladder distension.