a nurse is caring for a client who is at 39 weeks of gestation and is in active labor the nurse locates the fetal heart tones above the clients umbili
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ATI Maternal Newborn Proctored

1. A client who is at 39 weeks of gestation and is in active labor has fetal heart tones located above the umbilicus at midline. The fetus is likely in which of the following positions?

Correct answer: D

Rationale: Fetal heart tones above the umbilicus at midline are indicative of a breech presentation, specifically a frank breech position. In a frank breech position, the baby's buttocks are presenting first, which aligns with the fetal heart tones being above the umbilicus. This position indicates that the baby is not in the normal head-down position for birth, which can impact the delivery process and may require specific interventions. Cephalic presentation (Choice A) is the normal head-down position for birth, transverse lie (Choice B) is when the baby is positioned horizontally in the uterus, and posterior position (Choice C) refers to the baby's back being positioned towards the mother's back.

2. While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

Correct answer: A

Rationale: It is crucial to cover the newborn's eyes with an opaque eye mask to prevent damage to the retinas and corneas from the phototherapy light. The eyes are particularly sensitive to the light used in phototherapy, and shielding them helps protect the newborn's delicate eyes from potential harm. Choice B is incorrect because the newborn should be undressed to maximize skin exposure to the phototherapy light. Choice C is incorrect because lotions or oils can interfere with the effectiveness of phototherapy. Choice D is incorrect because the newborn should be kept as still as possible to maximize exposure to the light.

3. A client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?

Correct answer: C

Rationale: Maternal hypotension during pregnancy is often caused by the weight of the uterus pressing on the vena cava when the client is lying on her back, which reduces blood flow to the heart. This compression can lead to a decrease in blood pressure and subsequent symptoms of hypotension. Choice A is incorrect because an increase in blood volume typically leads to increased blood pressure rather than hypotension. Choice B is incorrect as pressure from the uterus on the diaphragm is not a common cause of maternal hypotension. Choice D is incorrect because increased cardiac output would not directly cause maternal hypotension.

4. A healthcare professional is providing information to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the healthcare professional include? (Select all that apply)

Correct answer: C

Rationale: Performing the pelvic rock exercise daily can help relieve backache during pregnancy by strengthening the back and abdominal muscles, providing support to the spine. This exercise is beneficial in maintaining proper posture and reducing strain on the back. Avoiding standing for prolonged periods can also help alleviate backache by reducing pressure on the spine and supporting muscles. Kegel exercises primarily focus on strengthening the pelvic floor muscles and may not directly help with backache during pregnancy. Avoiding any lifting is overly restrictive and not necessary, as long as proper lifting techniques are followed.

5. A client is receiving postpartum discharge teaching after being vaccinated for varicella due to lack of immunity. Which statement by the client indicates understanding?

Correct answer: B

Rationale: The correct answer is B because the client needs a second varicella vaccination at the postpartum visit to ensure immunity. Option A is incorrect as it implies a future need for a second vaccination without a clear action plan. Option C is incorrect as the varicella vaccine is primarily for the client's protection, not others. Option D is not the appropriate action as waiting to be tested for immunity delays the necessary second vaccination.

Similar Questions

A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?
A client with a BMI of 26.5 is seeking advice on weight gain during pregnancy at the first prenatal visit. Which of the following responses should the nurse provide?
A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?

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