a nurse is admitting a client to the labor and delivery unit when the client states my water just broke which of the following interventions is the nu
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ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. When a client states, 'My water just broke,' what is the nurse's priority intervention?

Correct answer: D

Rationale: The correct answer is D: Begin FHR monitoring. The priority intervention when a client's water breaks is to assess the fetal well-being due to the risk of umbilical cord prolapse. Monitoring the fetal heart rate (FHR) will help the nurse ensure the fetus's well-being. Performing Nitrazine testing (choice A) or assessing the fluid (choice B) may provide information about the rupture of membranes but does not directly address fetal well-being. Checking cervical dilation (choice C) is important but not the priority when the client's water has broken.

2. During an assessment of a client in labor who received epidural anesthesia, which finding should the nurse identify as a complication of the epidural block?

Correct answer: D

Rationale: Hypotension is a common complication of epidural anesthesia due to the vasodilation effect of the medication. Epidural anesthesia can lead to vasodilation, causing a decrease in blood pressure. This hypotension may result in decreased perfusion to vital organs and compromise maternal and fetal well-being. Tachycardia is less likely as a complication of epidural anesthesia since it tends to have a vasodilatory effect. Respiratory depression is more commonly associated with other forms of anesthesia, such as general anesthesia, rather than epidural anesthesia. Vomiting is not typically a direct complication of epidural anesthesia and is more commonly seen with other factors such as pain or medications given during labor.

3. A client who is at 22 weeks gestation is being educated by a nurse about the amniocentesis procedure. Which of the following statements should the nurse make?

Correct answer: C

Rationale: The correct answer is C. The nurse should advise the client to empty her bladder before an amniocentesis to minimize the risk of bladder puncture during the procedure. This precaution helps ensure the safety and accuracy of the procedure by reducing potential complications related to bladder puncture. Choices A, B, and D are incorrect because lying on the right side, fasting for 24 hours, and determining gestational age are not relevant instructions for an amniocentesis procedure.

4. 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.

5. A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?

Correct answer: D

Rationale: The correct answer is D, Postpartum blues. Postpartum blues, also known as baby blues, are common after childbirth and are characterized by symptoms like tearfulness, insomnia, lack of appetite, and a feeling of letdown. This condition is typically self-limiting and resolves without specific treatment. Postpartum fatigue (choice A) refers to extreme tiredness after childbirth but does not typically include symptoms like tearfulness and insomnia. Postpartum psychosis (choice B) is a severe condition that includes symptoms such as hallucinations and delusions, which are not present in the scenario. The letting-go phase (choice C) does not represent a specific postpartum condition related to the symptoms described.

Similar Questions

When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?
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 in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?
During a client's active labor, a healthcare provider notes that the presenting part is at 0 station. What is the correct interpretation of this clinical finding?
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