ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
Nurses' Notes: At 0625, the client is alert and oriented, at 38 weeks of gestation, presenting to the labor and delivery unit for evaluation of fluid leaking from the vagina. The client states they felt a small gush of fluid and thinks their membranes have ruptured. At 0830, mild contractions are occurring 20 minutes apart, irregular, lasting 40 seconds. The client rates the pain as a 3 on a scale of 0 to 10. An electronic fetal monitor is applied. The client voided 50 mL of clear yellow urine in a bedpan. Mild contractions are now 15 minutes apart, irregular, lasting 30 seconds. The cervix is 2 cm dilated with 20% effacement. The client rates pain as a 4 on a scale of 0 to 10. The fetal heart rate (FHR) is 132/min with moderate variability.
Question 1 of 5
The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
| Options | Indicated | Non-Essential | Contraindicated |
|---|---|---|---|
| Encourage frequent ambulation | |||
| Ensure the client maintains a supine position while in bed | |||
| Check FHR every 30 min | |||
| Perform a Nitrazine test | |||
| Prepare the client for catheterization | |||
| Obtain CBC blood sample | |||
| Check the client's temperature every hour |
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Anticipated, E: Nonessential, F: Nonessential, G: Anticipated
Rationale: A: Encourages labor progression. B: Can impede labor and fetal oxygenation. C: Ensures fetal well-being. D: Confirms rupture of membranes. E: Not needed with spontaneous voiding. F: No signs of infection. G: Monitors for infection post-rupture.
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Question 2 of 5
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