LPN LPN
ATI Maternal Newborn Proctored
1. A client in active labor is being prepared for epidural analgesia. Which of the following actions should the nurse take?
- A. Have the client sit upright on the bed with legs crossed.
- B. Administer a 500 mL bolus of lactated Ringer's solution prior to induction.
- C. Inform the client that the anesthetic effect will last for approximately 2 hours.
- D. Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction.
Correct answer: D
Rationale: Obtaining a 30-minute electronic fetal monitoring (EFM) strip prior to epidural analgesia is crucial to establish a baseline for fetal heart rate and uterine activity. This baseline helps in monitoring fetal well-being during labor and assessing the effect of analgesia on the baby. It enables the healthcare team to identify any changes in the fetal heart rate pattern and uterine contractions, ensuring the safety of both the mother and the baby. Choices A, B, and C are incorrect because having the client sit upright with legs crossed is not necessary for epidural placement, administering a bolus of lactated Ringer's solution is not typically done before epidural analgesia, and the duration of the anesthetic effect varies and is not accurately 2 hours.
2. A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?
- A. Maintain the client in the lithotomy position.
- B. Perform vaginal examinations frequently.
- C. Remind the client to bear down with each contraction.
- D. Encourage the client to empty her bladder every 2 hours.
Correct answer: D
Rationale: Encouraging the client to empty her bladder every 2 hours is essential during labor to prevent bladder distention, which can hinder labor progress and cause discomfort. A distended bladder can also lead to potential complications such as uterine atony or increased risk of infection. Choice A is incorrect as maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor and may not be comfortable for the client. Choice B is incorrect because performing vaginal examinations frequently can increase the risk of introducing infection and disrupt the natural progress of labor. Choice C is incorrect as bearing down with each contraction is typically reserved for the second stage of labor when the cervix is fully dilated, not during the active phase of the first stage.
3. A woman at 38 weeks of gestation is admitted in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
- A. Recheck the client's temperature in 4 hours.
- B. Administer glucocorticoids intramuscularly.
- C. Assess the odor of the amniotic fluid.
- D. Prepare the client for emergency cesarean section.
Correct answer: C
Rationale: An elevated temperature in a woman with ruptured membranes may indicate infection. Assessing the odor of the amniotic fluid can help determine if chorioamnionitis (an infection of the amniotic fluid) is present. This assessment is crucial to guide further interventions and management of the client's condition. Options A, B, and D are incorrect. Rechecking the client's temperature in 4 hours does not address the immediate concern of potential infection. Administering glucocorticoids intramuscularly is not indicated based solely on an elevated temperature. Preparing the client for an emergency cesarean section is premature and not supported by the information provided.
4. A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?
- A. On days 13 to 17 of her menstrual cycle
- B. Every morning before arising
- C. 1 hour following intercourse
- D. Before going to bed every night
Correct answer: B
Rationale: The basal body temperature should be taken every morning before arising as it provides the most accurate reading. This time ensures consistency and eliminates variations that may occur throughout the day due to activities or environmental factors. Choice A is incorrect because ovulation can vary among individuals, and checking temperature on specific days may not align with the actual ovulation day. Choice C is incorrect as there is no direct correlation between intercourse and basal body temperature. Choice D is incorrect because taking the temperature before going to bed does not provide a consistent baseline reading.
5. A client in labor is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
- A. Contractions that last for 60 seconds each with a 4-minute rest between contractions
- B. A contraction that lasts 4 minutes followed by a period of relaxation
- C. Contractions that last for 60 seconds each with a 3-minute rest between contractions
- D. Contractions that last 45 seconds each with a 3-minute rest between contractions
Correct answer: C
Rationale: The correct answer is C. When contractions are 4 minutes apart, it means there are 4 minutes from the start of one contraction to the start of the next. If each contraction lasts 60 seconds, there will be a 3-minute rest period between contractions. This allows for adequate uterine relaxation and recovery before the next contraction begins. Choice A is incorrect because it suggests a 4-minute rest between contractions, which is not accurate. Choice B is incorrect as contractions lasting 4 minutes continuously without rest would be concerning. Choice D is incorrect as it suggests 45-second contractions instead of 60-second contractions.
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