a nurse is preparing a client who is in active labor for epidural analgesia which of the following actions should the nurse take
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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?

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. During the admission assessment of a newborn, which anatomical landmark should be used for measuring the newborn's chest circumference?

Correct answer: B

Rationale: When measuring a newborn's chest circumference, the appropriate anatomical landmark to use is the nipple line. This point is consistent and allows for accurate and standardized measurements across all newborn assessments. The sternal notch is not typically used for chest circumference measurements in newborns. The xiphoid process is located at the lower end of the sternum and is not an appropriate landmark for chest circumference measurement. The fifth intercostal space is typically used for locating the point of maximal impulse (PMI) during cardiac assessments, not for measuring chest circumference.

3. A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)

Correct answer: D

Rationale: During early pregnancy, common discomforts include breast tenderness due to hormonal changes, urinary frequency caused by increased blood flow to the kidneys, and epistaxis (nosebleeds) due to increased blood volume and hormonal changes. Educating the client about these discomforts helps them understand what to expect during this stage. Choice D, 'All of the above,' is the correct answer because all the listed findings are common discomforts experienced during early pregnancy. Choices A, B, and C are individually correct as well, as breast tenderness, urinary frequency, and epistaxis are all common discomforts that pregnant individuals may encounter.

4. A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

5. 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.

Similar Questions

During a weekly prenatal visit, a nurse is assessing a client at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?
A woman in a women's health clinic is receiving teaching about nutritional intake during her 8th week of gestation. The healthcare provider should advise the woman to increase her daily intake of which of the following nutrients?
A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?
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)
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