RN ATI Comprehensive Assessment Exam Retake 2023 V2 -Nurselytic

Questions 58

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RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions

Extract:

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.



Vital Signs

0900:

Temperature 36.5°C (97.7°F)

BP 130/84 mm Hg

Heart rate 108/min

Respiratory rate 18/min

Oxygen saturation 98% on room air

0930:

BP 120/78 mm Hg

Heart rate 96/min

Respiratory rate 18/min

Oxygen saturation 98% on room air

1000:

BP 118/84 mm Hg

Heart rate 95/min

Respiratory rate 19/min

Oxygen saturation 97% on room air


Question 1 of 5

Select the 5 actions the nurse should take.

Correct Answer: B, C, D, E, F

Rationale: The correct actions (B, C, D, E, F) are based on managing a prolapsed umbilical cord during labor. B is crucial for timely intervention by involving the provider. C (Trendelenburg position) helps alleviate pressure on the cord. D (upward pressure) helps relieve compression on the cord. E aims to prevent cord compression. F (oxygen) supports fetal oxygenation. A is incorrect as increasing IV flowrate isn't a priority. G is not provided.

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:

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