a nurse is assisting in the care of a client who is in active labor the nurse notes tachycardia on the external fetal monitor tracing which of the fol
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ATI LPN

Maternal Newborn ATI Proctored Exam

1. During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

Correct answer: A

Rationale: Maternal fever can lead to fetal tachycardia due to the transmission of maternal fever to the fetus. This can result in an increased fetal heart rate, making it the correct potential cause in this scenario. Fetal heart failure (choice B) would typically present with bradycardia rather than tachycardia, making it an incorrect choice. Maternal hypoglycemia (choice C) is more likely to cause fetal distress rather than tachycardia. Fetal head compression (choice D) may lead to decelerations in the fetal heart rate pattern, but not necessarily tachycardia.

2. A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

Correct answer: B

Rationale: Tocolytic therapy is used to suppress premature labor. It is appropriate to administer it to a client experiencing preterm labor at 26 weeks of gestation to help delay delivery and improve neonatal outcomes. Administering tocolytic therapy to a client experiencing fetal death, Braxton-Hicks contractions, or post-term pregnancy is not indicated and may not be safe or effective in these situations. Fetal death at 32 weeks indicates a non-viable pregnancy, Braxton-Hicks contractions are normal and not indicative of preterm labor, and post-term pregnancy at 42 weeks does not require tocolytic therapy.

3. A healthcare professional in the emergency department is caring for a client who presents with severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the healthcare professional that the client has blood in the peritoneum?

Correct answer: B

Rationale: Cullen's sign, which presents as bruising around the umbilicus, indicates the presence of blood in the peritoneum. This sign is significant in cases of a ruptured ectopic pregnancy as it suggests intraperitoneal bleeding, prompting immediate medical attention. Chvostek's sign is related to facial muscle spasm and is not indicative of peritoneal bleeding. Chadwick's sign refers to a bluish discoloration of the cervix and vagina during pregnancy, not related to peritoneal bleeding. Goodell's sign is a softening of the cervix, which is a sign of pregnancy, and not specific to peritoneal bleeding.

4. When reinforcing teaching with new parents on bathing a newborn, a nurse observes a bluish-brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation?

Correct answer: A

Rationale: A bluish-brown marking across the lower back is more commonly seen in newborns with dark skin. These markings are known as Mongolian spots and are benign. They are not related to hyperbilirubinemia, forceps marks, or trauma during delivery. Choice B is incorrect because hyperbilirubinemia presents as jaundice, not as a bluish-brown marking. Choice C is incorrect because forceps marks would have a different appearance and location. Choice D is incorrect as Mongolian spots are not related to prolonged birth or trauma during delivery.

5. A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct answer is to apply an ice pack to the affected area. Ice packs help reduce swelling, inflammation, and provide pain relief post-episiotomy. Applying heat, as in a hot pack or warm sitz bath, can increase swelling and discomfort. Providing antiseptic solution in a squeeze bottle is not the first-line intervention for managing episiotomy pain, as the priority is pain relief and comfort.

Similar Questions

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
A client who is 2 hours postpartum is in the taking-hold phase. Which intervention should the nurse plan to implement during this phase of postpartum behavioral adjustment?
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