a client who is at 8 weeks of gestation tells the nurse i am not sure i am happy about being pregnant which of the following responses should the nurs
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam

1. A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?

Correct answer: B

Rationale: During the first few months of pregnancy, it is common for individuals to experience mixed feelings due to hormonal changes and the significant life adjustments that come with pregnancy. The nurse's response should acknowledge the client's feelings as normal and provide reassurance rather than dismissive or directive statements. By acknowledging the normalcy of these emotions, the nurse validates the client's experience and offers support during this critical time. Choices A, C, and D are less appropriate. Choice A focuses on informing the provider without addressing the client's emotions directly. Choice C disregards the client's current feelings and imposes a specific emotional response. Choice D jumps to scheduling a counseling appointment without first acknowledging the client's emotions or providing immediate support and validation.

2. 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.

3. 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.

4. When checking for the Moro reflex in a newborn, what action should the nurse take?

Correct answer: D

Rationale: The correct action to check for the Moro reflex in a newborn is to hold the newborn in a semi-sitting position and then allow the newborn's head and trunk to fall backward. The Moro reflex is elicited by a sudden loss of support or a loud noise. The normal response involves symmetrical abduction and extension of the arms, followed by their return to the midline in an embracing motion. Choices A, B, and C do not describe the correct method for assessing the Moro reflex and are therefore incorrect.

5. A client who received carboprost for postpartum hemorrhage is being assessed by a nurse. Which of the following findings is an adverse effect of this medication?

Correct answer: A

Rationale: The correct answer is A: Hypertension. Carboprost is a vasoconstrictor medication used to control postpartum hemorrhage by contracting the uterus. One of the adverse effects of carboprost is hypertension due to its vasoconstrictive properties. Hypertension can occur as a result of increased peripheral vascular resistance. Choices B, C, and D are incorrect. Hypothermia, constipation, and muscle weakness are not typically associated with the administration of carboprost. It is crucial for the nurse to monitor the client's blood pressure closely while on carboprost to promptly detect and manage hypertension.

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