a nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control which of the following actions should the
Logo

Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct action is to monitor the client's blood pressure every 5 to 10 minutes following the first dose of anesthetic solution to assess for maternal hypotension. This is crucial to detect and manage potential complications associated with the epidural anesthesia. Positioning the client supine for a prolonged period can lead to hypotension; administering dextrose solution is not a standard practice in epidural anesthesia; ensuring NPO status for 4 hours is not necessary before epidural placement.

2. A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

3. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. A continuous high-pitched cry is a characteristic sign of neonatal abstinence syndrome, indicating withdrawal from drugs. Choices A, C, and D are incorrect because decreased muscle tone, sleeping for 2 to 3 hours after a feeding, and mild tremors when disturbed are not specific indicators of neonatal abstinence syndrome.

4. A client with pregestational type 1 diabetes mellitus is being taught by a nurse about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. It is essential for a client with pregestational type 1 diabetes mellitus to continue taking insulin as prescribed even if they experience nausea and vomiting. This is crucial to prevent fluctuations in blood glucose levels that could lead to serious complications. Choice A is incorrect because the fasting blood glucose target for pregnant women with diabetes is usually lower. Choice B is incorrect as engaging in exercise when blood glucose is high is not recommended. Choice D is incorrect as avoiding exercise is not the appropriate approach when blood glucose levels are elevated.

5. A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct answer is to apply an ice pack to the affected area. Ice packs help reduce swelling, inflammation, and provide pain relief post-episiotomy. Applying heat, as in a hot pack or warm sitz bath, can increase swelling and discomfort. Providing antiseptic solution in a squeeze bottle is not the first-line intervention for managing episiotomy pain, as the priority is pain relief and comfort.

Similar Questions

A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?
A client presents with uterine hypotonicity and postpartum hemorrhage. Which action should the nurse prioritize?
While observing the electronic fetal heart rate monitor tracing for a client at 40 weeks of gestation in labor, a nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
A client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, 'I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device.' The nurse should suspect which of the following?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses