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ATI NUR223 Absection 4 Maternity Final Exam Questions

Extract:

A nurse is assessing a client who is at 39 weeks of gestation and in active labor. The client reports leakage of fluid and the nurse notes a small amount of clear fluid in the client's perineal area.


Question 1 of 5

Which of the following actions should the nurse take first?

Correct Answer: A

Rationale: A nitrazine test confirms rupture of membranes by detecting amniotic fluid's alkaline pH, guiding further management.

Extract:

A nurse is assisting a client with breastfeeding.


Question 2 of 5

The nurse explains that which of the following reflexes will promote the newborn to latch?

Correct Answer: C

Rationale: The rooting reflex prompts the newborn to turn toward a stimulus and open its mouth, aiding latching.

Extract:

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor.


Question 3 of 5

Which of the following assessment findings should the nurse report to the provider first?

Correct Answer: C

Rationale: Prolonged contractions (2 min) risk fetal hypoxia, requiring immediate provider notification.

Extract:

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period.


Question 4 of 5

Which of the following is the priority nursing intervention at this time?

Correct Answer: C

Rationale: Excessive bleeding suggests uterine atony; palpating the fundus assesses uterine tone, guiding interventions to prevent hemorrhage.

Extract:

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.


Question 5 of 5

Which of the following actions should the nurse complete at this time?

Correct Answer: D

Rationale: A displaced fundus suggests a full bladder, which can inhibit uterine contraction; having the client urinate relieves bladder pressure and aids uterine positioning.

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