ATI RN
ATI Nur 232 Maternity Final Exam SP24 Questions
Extract:
A nurse is caring for a client who is experiencing a decrease in the fetal heart rate.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Changing the client's position is the first action to relieve potential umbilical cord compression, which may improve fetal heart rate.
Extract:
Medical History: Gravida: 2, Para: 1, Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant, Client has no outstanding medical, social, or surgical history, Plan is to induce labor using oxytocin. Nurse's Notes at 0700 hrs: Client is resting in bed, appears anxious about the induction process. Reports mild, irregular contractions, stating they began around midnight. Fetal heart rate (FHR) is 140 beats per minute, with moderate variability. Cervix is 2 cm dilated, 50% effaced, and the fetal head is at -2 station. Client's partner is present and providing support. IV line is in place, and oxytocin infusion is started at 2 mU/min. Client is encouraged to ambulate as tolerated. Nurse's Notes at 0900 hrs: Client reports increased intensity and frequency of contractions, now occurring every 3-4 minutes. FHR is 145 beats per minute, with moderate variability and occasional accelerations. Cervix is now 4 cm dilated, 70% effaced, and the fetal head is at -1 station. Client is experiencing back pain and requests pain relief. IV oxytocin infusion is increased to 6 mU/min as per protocol. Client is repositioned to a side-lying position for comfort. Partner continues to provide support and encouragement. Vital Signs at 0700 hrs: Temperature: 37.2°C (99°F), Blood Pressure: 120/80 mmHg, Heart Rate: 82 beats per minute, Respiratory Rate: 18 breaths per minute. Vital Signs at 0900 hrs: Temperature: 37.5°C (99.5°F), Blood Pressure: 122/78 mmHg, Heart Rate: 88 beats per minute, Respiratory Rate: 20 breaths per minute. Diagnostic Results at 0900 hrs: Fetal scalp pH: 7.25, Amniotic fluid: Clear, no meconium present. A nurse is caring for a client who is 42 weeks of gestation.
Question 2 of 5
Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated.
| Action | anticipated | nonessential | contraindicated |
|---|---|---|---|
| Increase the oxytocin infusion to 13 mU/min | |||
| Place client in a side-lying position | |||
| Initiate bolus of primary IV fluids | |||
| Apply oxygen at 10 L/min via venturi mask | |||
| Perform sterile vaginal exam | |||
| Assign a Bishop score | |||
| Perform an amniotomy |
Correct Answer: A: Anticipated, B: Anticipated, C: Anticipated, D: Nonessential, E: Anticipated, F: Nonessential, G: Nonessential
Rationale: Increasing the oxytocin infusion to 13 mU/min is anticipated as contractions are progressing and cervical dilation is increasing. Placing the client in a side-lying position is anticipated to improve circulation and alleviate back pain. Initiating a bolus of IV fluids is anticipated to prevent dehydration during labor. Applying oxygen is nonessential as there are no signs of respiratory distress. Performing a sterile vaginal exam is anticipated to monitor labor progression. Assigning a Bishop score is nonessential since labor is already progressing. Performing an amniotomy is nonessential as labor is progressing normally without intervention.
Extract:
A nurse is assessing a newborn immediately after a scheduled cesarean delivery.
Question 3 of 5
Which of the following assessments should be the nurse's priority?
Correct Answer: C
Rationale: Respiratory distress is the priority assessment post-cesarean due to the risk of transient tachypnea of the newborn.
Extract:
A client at 37 weeks gestation is admitted with complaints of fever, pain and swelling in her groin, and contractions every 15 minutes. The nurse, when assessing the client's perineum, found erythematous lesions on the vulva that look like herpes.
Question 4 of 5
The nurse anticipates the patient's treatment regimen to include which of the following?
Correct Answer: C
Rationale: Acyclovir is the antiviral treatment for herpes, addressing the viral infection indicated by the lesions.
Extract:
A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client soaked a perineal pad in 10 minutes, the client's skin color is ashen, and she states she feels weak and light-headed. After applying oxygen via a non-rebreather face mask at 10 L/min.
Question 5 of 5
Which of the following actions should the nurse take next?
Correct Answer: C
Rationale: Massaging the fundus is the next action to address postpartum hemorrhage, indicated by heavy bleeding and symptoms of shock, by promoting uterine contractions to control bleeding.