a nurse is assisting with the care of a client who is pregnant and undergoing a nonstress test the client asks why the nurse is using an acoustic vibr
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam

1. During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?

Correct answer: D

Rationale: The acoustic vibration device is utilized during a nonstress test to awaken a sleeping fetus. This action helps ensure more accurate test results by eliciting fetal movements and heart rate accelerations, which are indicators of fetal well-being. Choices A, B, and C are incorrect because the primary purpose of the acoustic vibration device during a nonstress test is not to stimulate uterine contractions, decrease uterine contractions, or lull the fetus to sleep. Instead, it is specifically used to awaken a sleeping fetus to assess fetal well-being.

2. During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?

Correct answer: C

Rationale: The correct answer is C: "Breech." The RSA position indicates that the fetus is in a breech presentation. In a breech presentation, the buttocks or feet are positioned to be delivered first, which can impact the mode of delivery and require close monitoring during labor and birth. Choice A (Vertex) refers to the head-first presentation, which is considered the normal and most common presentation for birth. Choice B (Shoulder) does not represent a specific fetal presentation. Choice D (Mentum) refers to the chin presentation, which is also not relevant in this scenario.

3. A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

Correct answer: A

Rationale: The priority nursing intervention in this situation is to palpate the client's uterine fundus. A boggy uterus that is not well contracted may indicate uterine atony, which can lead to postpartum hemorrhage. Palpating the fundus and massaging it if it is boggy helps to promote contractions and reduce bleeding, making it the most critical intervention to address the potential underlying issue. Assisting the client to a bedpan to urinate, preparing to administer oxytocic medication, or increasing the client's fluid intake are not the immediate priorities in this scenario compared to assessing and addressing the uterine fundus status.

4. A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?

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 full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

Correct answer: B

Rationale: A newborn's respiratory rate can vary between 20 to 100 breaths per minute during the initial phase after birth. A respiratory rate as low as 18 breaths per minute at this early stage requires immediate nursing intervention. This finding necessitates further assessment to ensure adequate oxygenation and respiratory function. The other options, heart rate of 168/min, tremors, and fine crackles, are within normal limits for a full-term newborn and do not require immediate intervention.

Similar Questions

A healthcare professional is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition?
A nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?
A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
A client who is at 39 weeks of gestation and is in active labor has fetal heart tones located above the umbilicus at midline. The fetus is likely in which of the following positions?
A client at 32 weeks of gestation with placenta previa is actively bleeding. Which medication should the provider likely prescribe?

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