a nurse is caring for a client who is in labor and reports increasing rectal pressure she is experiencing contractions 2 to 3 min apart each lasting 8
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?

Correct answer: B

Rationale: The client is in the transition phase of labor, characterized by cervical dilatation of 8 to 10 cm and contractions every 2 to 3 minutes, each lasting 45 to 90 seconds. In this phase, the cervix is nearly fully dilated, preparing the client for the pushing stage. The active phase of labor typically involves cervical dilatation from 4 to 7 cm, whereas the latent phase is the early phase of labor when the cervix dilates from 0 to 3 cm. Descent is not a phase of labor but rather refers to the movement of the fetus through the birth canal during the second stage of labor.

2. A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?

Correct answer: C

Rationale: Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.

3. A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?

Correct answer: A

Rationale: The correct answer is 'Moderate lochia rubra.' On the second day postpartum, it is normal for lochia to be bright red and contain small clots, indicating moderate lochia rubra. This amount of bleeding is expected as the uterus continues to shed its lining after childbirth. Excessive lochia serosa, light lochia rubra, and scant lochia serosa do not accurately reflect the described scenario. Excessive lochia serosa is more characteristic of a later postpartum period, while light and scant lochia serosa are not consistent with the bright red color and small clots observed in this case.

4. 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?

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.

5. A newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight should be classified as which of the following?

Correct answer: B

Rationale: The classification of a newborn as appropriate for gestational age is determined by considering the weight and gestational age. In this case, the newborn's weight falls within the normal range for the gestational age, indicating that the newborn is appropriately sized for the length of time spent in the womb. Choice A, 'Low birth weight,' is incorrect as the newborn's weight is within the normal range. Choice C, 'Small for gestational age,' is incorrect because the newborn's weight is not below the 10th percentile for gestational age. Choice D, 'Large for gestational age,' is incorrect as the newborn's weight is not above the 90th percentile, rather falling within the 60th percentile which is considered normal.

Similar Questions

When caring for clients in a prenatal clinic, a nurse should report which client's weight gain to the provider?
During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?
A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?
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?

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