a nurse is assessing a client who is in active labor the fhr baseline has been 100min for the past 15 minutes what condition should the nurse suspect
Logo

Nursing Elites

ATI RN

ATI Exit Exam 2023

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

Correct answer: C

Rationale: In this scenario, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.

2. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

3. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.

4. A client has a new diagnosis of COPD. Which of the following instructions should the nurse include in the teaching?

Correct answer: B

Rationale: Pursed-lip breathing is a beneficial technique for clients with COPD as it helps control shortness of breath and improves oxygenation. This technique involves inhaling slowly through the nose and exhaling through pursed lips, which helps keep airways open. Option A is incorrect as breathing rapidly through the mouth when using the incentive spirometer can lead to hyperventilation. Option C is incorrect because it is important for clients with COPD to stay hydrated by drinking fluids between meals, but not during meals which can cause bloating and discomfort. Option D is incorrect as diaphragmatic breathing, though beneficial, is not the preferred technique for managing dyspnea in COPD; pursed-lip breathing is more effective.

5. A client with a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D: "Trim your toenails straight across." This instruction is essential to prevent ingrown toenails in clients with diabetes. Soaking feet in warm water daily (choice A) may increase the risk of skin breakdown and infection. Wearing shoes one size larger than normal (choice B) can lead to friction and cause blisters. While wearing cotton socks (choice C) is generally recommended, the emphasis should be on moisture-wicking materials rather than just cotton.

Similar Questions

A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?
A client prescribed clozapine is receiving discharge teaching from a nurse. Which statement by the client indicates an understanding of the teaching?
What is the most important nursing action when a patient has a central line?
A client at 32 weeks of gestation with preeclampsia is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research, the nurse should identify which of the following electronic databases has the most comprehensive collection of nursing articles?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses