ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Admission Assessments: Client admitted to labor and delivery. Gravida 1, para 0 at 40 weeks of gestation, presents with contractions every 5 to 6 min, 30 to 40 seconds duration, 2+ intensity. Client reports their water broke and the fluid was clear. Positive for group B Streptococcus B-hemolytic at 37 weeks. Sterile vaginal examination. Cervix 5 cm dilated, 50% effaced, and 0 station. Flow Sheet: 1130:
Fetal heart rate 140/min with moderate variability. Intermittent accelerations. Contractions moderate, average 80 seconds duration.
1210:
Fetal heart rate 140/min with moderate variability. Early deceleration. Contractions moderate, average 90 seconds duration.
1215:
Fetal heart rate 120/min with minimal variability Early decelerations. Vital Sign:1130:
Temperature 36.4° C (97.5° F)
Heart rate 84/min
Respiratory rate 18/min
BP 124/82 mm Hg
1200:
Temperature 36.5° C (97.7° F)
Heart rate 90/min.
Respiratory rate 18/min
BP 128/84 mm Hg
1215:
Temperature 37.1° C (98.8° F)
Heart rate 86/min
Respiratory rate 18/min
BP 120/80 mm Hg
Question 1 of 5
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client: A. Decrease the IV flow rate, B. Monitor fetal heart rate, C. Administer ampicillin IV, D. Place client in left lateral position, E. Request a prescription for ephedrine.
| Options | Essential | Contrainidication |
|---|---|---|
| Decrease the IV flow rate | ||
| Monitor fetal heart rate | ||
| Administer ampicillin IV | ||
| Place client in left lateral position | ||
| Request a prescription for ephedrine |
Correct Answer:
Rationale:
To determine the correct answer, we must consider the implications of an epidural insertion. Decreasing the IV flow rate is essential to prevent hypotension which can occur due to the epidural anesthesia. Monitoring fetal heart rate is essential to ensure fetal well-being. Administering ampicillin IV and requesting ephedrine are not directly related to the client's condition post-epidural, so they are contraindicated. Placing the client in the left lateral position helps to optimize blood flow to the placenta and is essential post-epidural.
Therefore, the correct answer is .
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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