ATI LPN
ATI Maternal Newborn Proctored
1. A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct answer: D
Rationale: Turning the client onto her side is the appropriate nursing intervention in this scenario. This position can help improve blood pressure by enhancing venous return, which may aid in increasing perfusion to vital organs. It can also alleviate pressure on the inferior vena cava, promoting better circulation and supporting blood pressure stabilization during labor. Choices A, B, and C are incorrect. A cesarean birth is not indicated based on the information provided. Assisting the client to an upright position may worsen her blood pressure due to decreased venous return. Lastly, there is no indication for an immediate vaginal delivery solely based on the client's blood pressure reading.
2. The healthcare provider is caring for a patient who is taking warfarin (Coumadin). Which laboratory value should the healthcare provider monitor closely?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Hemoglobin level.
- D. White blood cell count.
Correct answer: B
Rationale: Corrected Rationale: When caring for a patient on warfarin, monitoring prothrombin time (PT) is crucial. PT helps assess the blood's ability to clot properly, ensuring the patient maintains therapeutic anticoagulation levels while minimizing bleeding risks. Platelet count (Choice A) is important but not the most critical for warfarin therapy. Hemoglobin level (Choice C) and white blood cell count (Choice D) are not directly related to monitoring the effects of warfarin.
3. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:
- A. Sleep Pattern Disturbance related to pain.
- B. Pain related to ear infection.
- C. Altered Family Processes related to ill child.
- D. Ineffective Thermoregulation Related to Infection
Correct answer: B
Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.
4. The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?
- A. Take daily weights and monitor trends.
- B. Encourage fluid intake to improve hydration.
- C. Elevate the legs above the level of the heart.
- D. Position the client supine with the head of the bed at 30 degrees.
Correct answer: A
Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early. Encouraging fluid intake (Choice B) might exacerbate fluid overload in a client with elevated BNP levels. Elevating the legs (Choice C) and positioning the client supine with the head of the bed at 30 degrees (Choice D) are interventions more suitable for clients with hypotension, not specifically indicated for managing elevated BNP levels.
5. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.
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