ATI LPN
ATI Maternal Newborn Proctored
1. A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing fetal death at 32 weeks of gestation
- B. A client who is experiencing preterm labor at 26 weeks of gestation
- C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
- D. A client who has a post-term pregnancy at 42 weeks of gestation
Correct answer: B
Rationale: Tocolytic therapy is used to suppress premature labor. It is appropriate to administer it to a client experiencing preterm labor at 26 weeks of gestation to help delay delivery and improve neonatal outcomes. Administering tocolytic therapy to a client experiencing fetal death, Braxton-Hicks contractions, or post-term pregnancy is not indicated and may not be safe or effective in these situations. Fetal death at 32 weeks indicates a non-viable pregnancy, Braxton-Hicks contractions are normal and not indicative of preterm labor, and post-term pregnancy at 42 weeks does not require tocolytic therapy.
2. A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?
- A. Dark green leafy vegetables
- B. Deep red or orange vegetables
- C. White bread and rice
- D. Meat, poultry, and fish
Correct answer: A
Rationale: Dark green leafy vegetables are rich in calcium, making them an excellent alternative source for individuals who dislike or cannot consume dairy products. Calcium is crucial for bone health, particularly during pregnancy, to support the developing fetus and maintain the mother's bone strength. Therefore, recommending dark green leafy vegetables ensures the client receives an adequate intake of calcium despite not liking milk. Choice B, deep red or orange vegetables, are not typically high in calcium. Choice C, white bread and rice, are not significant sources of calcium. Choice D, meat, poultry, and fish, are good sources of protein but do not provide as much calcium as dark green leafy vegetables.
3. During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?
- A. Maternal fever
- B. Fetal heart failure
- C. Maternal hypoglycemia
- D. Fetal head compression
Correct answer: A
Rationale: Maternal fever can lead to fetal tachycardia due to the transmission of maternal fever to the fetus. This can result in an increased fetal heart rate, making it the correct potential cause in this scenario. Fetal heart failure (choice B) would typically present with bradycardia rather than tachycardia, making it an incorrect choice. Maternal hypoglycemia (choice C) is more likely to cause fetal distress rather than tachycardia. Fetal head compression (choice D) may lead to decelerations in the fetal heart rate pattern, but not necessarily tachycardia.
4. A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?
- A. I will inform the provider that you are having these feelings.
- B. It is normal to have these feelings during the first few months of pregnancy.
- C. You should be happy that you are going to bring new life into the world.
- D. I am going to make an appointment with the counselor for you to discuss these thoughts.
Correct answer: B
Rationale: During the first few months of pregnancy, it is common for individuals to experience mixed feelings due to hormonal changes and the significant life adjustments that come with pregnancy. The nurse's response should acknowledge the client's feelings as normal and provide reassurance rather than dismissive or directive statements. By acknowledging the normalcy of these emotions, the nurse validates the client's experience and offers support during this critical time. Choices A, C, and D are less appropriate. Choice A focuses on informing the provider without addressing the client's emotions directly. Choice C disregards the client's current feelings and imposes a specific emotional response. Choice D jumps to scheduling a counseling appointment without first acknowledging the client's emotions or providing immediate support and validation.
5. A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)
- A. Breast tenderness
- B. Urinary frequency
- C. Epistaxis
- D. All of the above
Correct answer: D
Rationale: During early pregnancy, common discomforts include breast tenderness due to hormonal changes, urinary frequency caused by increased blood flow to the kidneys, and epistaxis (nosebleeds) due to increased blood volume and hormonal changes. Educating the client about these discomforts helps them understand what to expect during this stage. Choice D, 'All of the above,' is the correct answer because all the listed findings are common discomforts experienced during early pregnancy. Choices A, B, and C are individually correct as well, as breast tenderness, urinary frequency, and epistaxis are all common discomforts that pregnant individuals may encounter.
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