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 with a BMI of 26.5 is seeking advice on weight gain during pregnancy at the first prenatal visit. Which of the following responses should the nurse provide?
- A. It would be best if you gained about 11 to 20 pounds.
- B. The recommendation for you is about 15 to 25 pounds.
- C. A gain of about 25 to 35 pounds is recommended for you.
- D. A gain of about 1 pound per week is the best pattern for you.
Correct answer: B
Rationale: For a client with a BMI of 26.5 (overweight), the recommended weight gain during pregnancy is 15 to 25 pounds. This range helps promote a healthy pregnancy outcome and reduces the risk of complications associated with excessive weight gain. Option A suggests a lower weight gain range, which may not be adequate for a client with a BMI of 26.5. Option C indicates a higher weight gain range, which could lead to complications for an overweight individual. Option D provides a general guideline for weight gain without considering the client's BMI, which is not personalized advice. Therefore, the most appropriate response is option B, offering a suitable weight gain recommendation for the client's BMI to support a healthy pregnancy journey.
3. After an amniotomy, what is the priority nursing action?
- A. Observe color and consistency of fluid
- B. Assess the fetal heart rate pattern
- C. Assess the client's temperature
- D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation
Correct answer: B
Rationale: After an amniotomy, the priority nursing action is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress, as changes in the fetal heart rate could indicate potential complications related to the procedure. Observing the color and consistency of the fluid (Choice A) is important but not the priority over assessing fetal well-being. Assessing the client's temperature (Choice C) and evaluating the client for chills and increased uterine tenderness (Choice D) are not immediate priorities following an amniotomy.
4. While observing the electronic fetal heart rate monitor tracing for a client at 40 weeks of gestation in labor, a nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
- A. Early decelerations
- B. Accelerations
- C. Late decelerations
- D. Variable decelerations
Correct answer: D
Rationale: Variable decelerations can indicate umbilical cord compression, which is a concern that may arise due to the umbilical cord being compressed during labor. This compression can lead to reduced blood flow and oxygen delivery to the fetus, necessitating close monitoring and potentially interventions to alleviate the pressure on the cord. Early decelerations are typically benign and mirror the contractions, indicating fetal head compression. Accelerations are reassuring patterns that show a healthy response to fetal movement. Late decelerations are concerning as they suggest uteroplacental insufficiency, indicating potential oxygen deprivation to the fetus.
5. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?
- A. 1+ pitting sacral edema
- B. 3+ protein in the urine
- C. Blood pressure 148/98 mm Hg
- D. Deep tendon reflexes of +1
Correct answer: D
Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.
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