ATI LPN
ATI Maternal Newborn
1. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct answer: B
Rationale: The priority action for the nurse in this situation is to position the client with one hip elevated. This position can help improve blood flow to the placenta and stabilize blood pressure, which is crucial for both the client and the fetus during labor. It can also help optimize fetal oxygenation by improving circulation. Notifying the provider of the findings may be necessary, but ensuring proper positioning of the client takes precedence to address the immediate physiological needs. Asking the client about pain medication or having the client void are important interventions but are not the priority in this scenario where the client is experiencing painful contractions and has low blood pressure.
2. What is the cause of gas formation in the colon?
- A. Consuming refined foods.
- B. Drinking excess water.
- C. Swallowing air while eating.
- D. Bacterial action on organic compounds.
Correct answer: D
Rationale: Gas formation in the colon is primarily due to bacterial fermentation of undigested carbohydrates. Choice A, consuming refined foods, is incorrect as gas formation is not directly linked to refined foods but rather undigested carbohydrates. Choice B, drinking excess water, is incorrect as water consumption does not lead to gas formation in the colon. Choice C, swallowing air while eating, is incorrect as this may cause belching but not gas formation in the colon. The correct answer is D because bacterial action on organic compounds, specifically undigested carbohydrates, leads to gas production in the colon.
3. Which of the following best describes the role of a community health nurse?
- A. Providing acute care in hospitals
- B. Conducting surgeries
- C. Promoting health and preventing disease in the community
- D. Diagnosing and treating medical conditions
Correct answer: C
Rationale: The primary role of a community health nurse is to focus on promoting health and preventing disease within the community. They work to improve the overall health and well-being of individuals and populations by providing education, preventive care, and support to enhance community health outcomes. Community health nurses collaborate with community members, organizations, and public health agencies to address health disparities, implement health promotion strategies, and advocate for equitable access to healthcare services.
4. The healthcare provider is providing postpartum care to a client who had a vaginal delivery. Which finding would require further assessment?
- A. Perineal swelling
- B. Moderate lochia serosa
- C. Headache unrelieved by analgesics
- D. Breast engorgement
Correct answer: C
Rationale: A headache unrelieved by analgesics can be a sign of a serious condition such as preeclampsia, which is a life-threatening condition characterized by high blood pressure and often protein in the urine. Prompt assessment and intervention are crucial to prevent complications for both the mother and baby.
5. Signs of malnutrition can appear when:
- A. nutrient reserves are depleted.
- B. nutrient intake exceeds daily needs.
- C. energy intake is restricted.
- D. caloric expenditure increases.
Correct answer: A
Rationale: The correct answer is A: 'nutrient reserves are depleted.' Signs of malnutrition manifest when the body's reserves of essential nutrients are exhausted and can no longer sustain health. Choice B is incorrect because excessive nutrient intake exceeding daily needs does not lead to malnutrition but may cause other health issues. Choice C is incorrect as restricting energy intake may lead to weight loss but not necessarily malnutrition. Choice D is also incorrect as increasing caloric expenditure does not directly cause malnutrition.
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