a nurse is caring for a client who is at 38 weeks gestation is in active labor and has ruptured membrane which of the following actions should the nur
Logo

Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam

1. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

2. Which of the following interventions is considered the most effective form of universal precautions?

Correct answer: B

Rationale: The most effective form of universal precautions is to discard all used uncapped needles and syringes in an impenetrable protective container. This practice minimizes the risk of needle-stick injuries, which are a significant concern when dealing with used needles. By safely disposing of uncapped needles, healthcare providers can protect themselves and others from potential exposure to bloodborne pathogens.

3. A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?

Correct answer: C

Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.

4. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

Correct answer: C

Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.

5. What term refers to the manner of walking?

Correct answer: A

Rationale: Gait specifically refers to the manner in which a person walks. It encompasses the pattern, rhythm, and style of walking, making it the most appropriate term in this context. Choices B, C, and D are incorrect. Range of motion refers to the extent of movement of a joint, flexion and extension relate to bending and straightening movements at a joint, and hopping is a specific type of movement that involves jumping on one foot.

Similar Questions

A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?
A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?
A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
What is the appropriate needle gauge for intradermal injection?
While reviewing the laboratory results of a group of clients, which infection should the nurse in a provider's office report?

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