a nurse is providing discharge teaching to a client who is postpartum for which of the following clinical manifestations should the nurse instruct the
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. 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?

Correct answer: C

Rationale: Unilateral breast pain can be a sign of mastitis, an infection of the breast tissue, which requires prompt evaluation and treatment. The nurse should instruct the client to report this clinical manifestation to the provider to prevent complications and promote recovery.

2. Which of the following medications should the provider prescribe for a client with gonorrhea?

Correct answer: A

Rationale: Ceftriaxone is the preferred medication to treat gonorrhea, a bacterial infection. It is essential to promptly treat gonorrhea to prevent complications such as pelvic inflammatory disease, infertility, and the spread of the infection to others. Fluconazole is used for fungal infections, Metronidazole treats certain bacterial and parasitic infections, and Zidovudine is an antiretroviral medication used in HIV treatment; none of these are appropriate for gonorrhea.

3. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

4. A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?

Correct answer: C

Rationale: The nurse should assist the client into the hands and knees position during contractions to help relieve her back pain and facilitate the rotation of the fetus from the posterior to an anterior occiput position. This position can aid in optimal fetal positioning for delivery. Choice A, performing effleurage, is a massage technique that may provide comfort but does not address the fetal position. Placing the client in lithotomy position (Choice B) may not be ideal for a client experiencing back pain due to the occiput posterior position. Applying a scalp electrode to the fetus (Choice D) is not indicated solely for addressing the client's back pain.

5. When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?

Correct answer: C

Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.

Similar Questions

A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?
A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
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?
A client who is breastfeeding and has mastitis is receiving teaching from the nurse. Which of the following responses should the nurse make?
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

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