ATI Maternal Newborn Proctored Exam 2024

ATI Maternal Newborn Proctored Exam 2024 Related

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A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

  • A. Observe color and consistency of fluid.
  • B. Assess the fetal heart rate pattern.
  • C. Assess the client's temperature.
  • D. Evaluate client for the presence of chills and increased uterine tenderness using palpation.
Correct Answer: B

Rationale: The priority nursing action following an amniotomy (rupture of the amniotic sac) is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress or complications that may arise after the procedure. Changes in the fetal heart rate pattern can indicate the need for interventions to ensure the well-being of the fetus. Observing the color and consistency of the amniotic fluid, assessing the client's temperature, and evaluating for the presence of chills and increased uterine tenderness are also important assessments following amniotomy, but assessing the fetal heart rate takes precedence in this situation to ensure the safety of the fetus.

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A client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?

  • A. Administer tocolytic medication.
  • B. Perform a sterile vaginal examination.
  • C. Assess fetal heart rate and contraction pattern.
  • D. Encourage ambulation to relieve discomfort.
Correct Answer: C

Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.

A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

  • A. A peanut butter sandwich on wheat bread.
  • B. A sliced apple and red grapes.
  • C. A chocolate chip cookie with a glass of skim milk.
  • D. A scrambled egg with cheddar cheese.
Correct Answer: B

Rationale: Phenylketonuria (PKU) is a genetic disorder where the body cannot metabolize phenylalanine, an amino acid found in protein-containing foods. Patients with PKU need to follow a strict low-phenylalanine diet to prevent the buildup of phenylalanine in the body. Fruits like apples and grapes are low in protein and contain minimal phenylalanine, making them suitable choices for individuals with PKU. The other options listed contain higher amounts of protein and phenylalanine, such as peanut butter, chocolate chip cookies, milk, scrambled eggs, and cheese, which should be avoided by individuals with PKU.

What population is disproportionately affected by human trafficking, particularly for sexual exploitation?

  • A. older adults aged 65 and above
  • B. males in their late 20s and 30s
  • C. persons AFAB
  • D. individuals with higher education levels
Correct Answer: C

Rationale:

The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?

  • A. Cervix is dilated to 8 cm.
  • B. Fetal head is crowning.
  • C. Contractions every 3–5 minutes.
  • D. Client reports back pain.
Correct Answer: B

Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

  • A. Place the client in the lateral position.
  • B. Increase the rate of maintenance IV infusion.
  • C. Elevate the client's legs.
Correct Answer: A

Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.

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