ATI LPN
Maternal Newborn ATI Proctored Exam
1. While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct answer: D
Rationale: In the scenario of umbilical cord prolapse during labor, the nurse should first call for assistance. Umbilical cord prolapse is a critical obstetric emergency that requires immediate attention and skilled assistance. Calling for help ensures that additional support is on the way to provide prompt intervention. Placing the client in the Trendelenburg position (Choice A) is no longer recommended as it may worsen the situation. Applying finger pressure to the presenting part (Choice B) can further compress the cord. Administering oxygen (Choice C) is important but should come after addressing the prolapsed cord.
2. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct answer: A
Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.
3. A client has a new prescription for enalapril. Which of the following adverse effects should the client be instructed to monitor and report?
- A. Frequent urination
- B. Tremors
- C. Dry mouth
- D. Persistent cough
Correct answer: D
Rationale: The correct answer is D: Persistent cough. Enalapril, an ACE inhibitor, is known to commonly cause a persistent cough as an adverse effect due to its effect on bradykinin levels. Clients should be instructed to monitor for a persistent cough and report it promptly to their healthcare provider for further evaluation and possible medication adjustment. Choices A, B, and C are incorrect as they are not commonly associated with enalapril use and are not typical adverse effects of ACE inhibitors.
4. Which of the following individuals should be considered as special targets for family planning?
- A. Individuals with two or more children
- B. Individuals with medical conditions such as anemia
- C. Individuals younger than 20 years or older than 35 years
- D. Individuals who have had a delivery within the past 15 months
Correct answer: D
Rationale: Individuals who have had a delivery within the past 15 months should be considered special targets for family planning because the ideal birth spacing is at least two years. By waiting two years (15 months post-delivery + 9 months of pregnancy), the individual can give their body enough time to recover and reduce potential health risks associated with closely spaced pregnancies.
5. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused
- B. Request a prescription for PRN restraints when the client is wandering
- C. Dim the lighting in the client’s room
- D. Leave one side rail up on the client's bed
Correct answer: D
Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.
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