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
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: