a nurse is assessing a client who is in active labor and the fhr baseline has been 100min for 15 minutes what should the nurse suspect a nurse is assessing a client who is in active labor and the fhr baseline has been 100min for 15 minutes what should the nurse suspect
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?

Correct answer: C

Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.

2. A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?

Correct answer: C

Rationale: Vitamin C aids in the absorption of iron by enhancing the body's ability to absorb non-heme iron, which is found in plant-based foods. This vitamin helps convert iron into a form that is more easily absorbed in the intestines. Choices A, B, and D are incorrect because fiber, Vitamin A, and oxalates can actually inhibit the absorption of iron. Fiber can bind to iron and reduce its absorption, Vitamin A does not directly enhance iron absorption, and oxalates found in some foods like spinach and rhubarb can also hinder iron absorption.

3. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium and low sodium. The nutrition instructions should include:

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?

Correct answer: C

Rationale: Discussing how the body continuously makes blood helps the child understand that losing a small amount is normal and not harmful. This educational approach also helps reduce anxiety by giving the child a sense of control over the situation.

5. A client with HIV is starting therapy with zidovudine. The nurse should monitor the client for which of the following adverse effects of this medication?

Correct answer: A

Rationale: Fatigue is a common adverse effect of zidovudine due to its impact on bone marrow, leading to anemia. Zidovudine is known to cause bone marrow suppression, resulting in decreased production of red blood cells and subsequent fatigue.

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