ATI LPN
Maternal Newborn ATI Proctored Exam 2023
1. During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?
- A. Back rub
- B. Counter-pressure
- C. Playing music
- D. Foot massage
Correct answer: B
Rationale: In cases where the fetus is in a posterior position causing severe pressure and pain in the lower back during labor, applying counter-pressure is the most effective nonpharmacological intervention. Counter-pressure helps lift the fetal head off the spinal nerve, offering relief to the client. This technique is evidence-based and recommended to alleviate discomfort associated with a posterior fetal position. Choices A, C, and D are not as effective in this situation. While a back rub or playing music may provide some comfort, they do not directly address the issue caused by the fetal head's position. Similarly, a foot massage may offer relaxation but may not significantly relieve the specific discomfort arising from the posterior fetal position and the associated lower back pain.
2. A client has developed phlebitis at the IV site. What should the nurse do first?
- A. Apply a warm compress to the IV site
- B. Discontinue the IV and notify the provider
- C. Monitor the IV site for signs of infection
- D. Administer an anti-inflammatory medication
Correct answer: B
Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.
3. A client has a new prescription for a low-sodium diet. Which of the following foods should the nurse recommend?
- A. Pickles
- B. Canned soup
- C. Fresh fruits
- D. Smoked salmon
Correct answer: C
Rationale: Fresh fruits are naturally low in sodium, making them a suitable choice for a low-sodium diet. They provide essential nutrients and are a healthy option for individuals who need to limit their sodium intake. Pickles (Choice A) and canned soup (Choice B) are typically high in sodium and should be avoided in a low-sodium diet. Smoked salmon (Choice D) is also usually high in sodium due to the smoking process, so it is not a recommended choice for a low-sodium diet.
4. What is the primary nutritional function of the large intestine?
- A. Absorption of fats.
- B. Excretion of waste products.
- C. Excretion of bacteria.
- D. Absorption of water.
Correct answer: D
Rationale: The correct answer is D: Absorption of water. The primary nutritional function of the large intestine is to absorb water from the indigestible food residue that enters it from the small intestine. This absorption of water helps to form solid waste, which is then eliminated from the body. Choices A, B, and C are incorrect because the large intestine is not primarily responsible for the absorption of fats, excretion of waste products, or excretion of bacteria. While the large intestine does play a role in waste elimination and contains bacteria beneficial for digestion, its main function in terms of nutrition is the absorption of water.
5. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?
- A. High risk for altered body temperature - hyperthermia
- B. Ineffective breathing pattern
- C. Ineffective individual coping
- D. Knowledge deficit
Correct answer: B
Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.
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