a nurse is caring for a client during the first trimester of pregnancy after reviewing the clients blood work the nurse notices she does not have immu
Logo

Nursing Elites

ATI LPN

ATI Maternal Newborn Proctored

1. A client is in the first trimester of pregnancy and lacks immunity to rubella. When should the client receive rubella immunization?

Correct answer: A

Rationale: Rubella immunization is recommended shortly after giving birth for a pregnant individual who lacks immunity. This timing ensures the client is protected from rubella in future pregnancies. Administering the vaccine postpartum allows the body to develop immunity without posing any risk to the developing fetus during pregnancy. Option B is incorrect because administering the rubella vaccine in the third trimester can potentially expose the developing fetus to the live virus, which is not recommended. Option C is incorrect as there is a preferred timing for rubella immunization in this scenario. Option D is incorrect as waiting until the next attempt to get pregnant does not protect the current pregnancy from rubella exposure.

2. A client is being discharged after childbirth. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?

Correct answer: C

Rationale: Sore nipples with cracks and fissures should be reported to the provider as this can indicate improper breastfeeding techniques or infection, which requires medical evaluation and intervention to prevent further complications such as mastitis or decreased milk supply. Scant, non-odorous white vaginal discharge is a normal finding postpartum. Uterine cramping during breastfeeding is also common due to oxytocin release. Decreased response with sexual activity may be expected at 4 weeks postpartum due to hormonal changes and fatigue, but it is not typically a concern that needs immediate medical attention.

3. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

Correct answer: D

Rationale: The correct answer is D. In a persistent occiput posterior position, the baby's head presses against the mother's spine, causing prolonged labor and severe backache. This position can lead to difficulties in labor progress and increase discomfort for the mother. Choices A, B, and C are incorrect as they do not directly relate to the client's difficult, prolonged labor with severe backache. Fetal attitude, fetal lie, and maternal pelvis type may affect labor, but in this scenario, the persistent occiput posterior fetal position is the primary contributing cause for the client's symptoms.

4. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Correct answer: D

Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.

5. A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)

Correct answer: C

Rationale: During labor, effective pain management is crucial. The nurse should assist the client with patterned breathing techniques to help manage pain and administer opioid analgesic medication as ordered. Providing ice chips is a comfort measure but does not directly address pain relief. Inserting a urinary catheter is not typically indicated at this stage of labor unless there are specific medical indications, such as the need to closely monitor urine output. Therefore, the correct action for the nurse to prepare to take in this scenario is to administer opioid analgesic medication.

Similar Questions

A client who is pregnant states that her last menstrual period was April 1st. What is the client's estimated date of delivery?
A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. After an examination, the provider informs the client that the fetus has died, and the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?
A client who is at 22 weeks of gestation reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)
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?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses