ATI NSG 4525 INTRAPARTUM FINAL ACTUAL
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is caring for a client following an amniotomy who is now in the active phase
of the first stage of labor. Which of the following actions should the nurse implement
with this client?
-Maintain the client in the lithotomy position.
-Perform vaginal examinations frequently.
-Remind the client to bear down with each contraction.
-Encourage the client to empty her bladder every 2 hr. - ✔✔Encourage the client to
empty her bladder every 2 hr. -
A client in labor should be encouraged to empty her bladder every 2 hr. Bladder
distention can impede the descent of the fetus and slow the progression of labor. It can
also contribute to uterine atony after delivery, increasing the client's risk of postpartum
hemorrhage.
✔✔A nurse is caring for a client who is in the first stage of labor. The nurse observes
the umbilical cord protruding from the vagina. Which of the following actions should the
nurse perform first?
-Cover the cord with a sterile, moist saline dressing.
-Prepare the client for an immediate birth.
-Place the client in knee-chest position.
-Insert a gloved hand into the vagina to relieve pressure on the cord. - ✔✔Insert a
gloved hand into the vagina to relieve pressure on the cord. -
This is the first nursing action because it is essential to prevent any pressure on the
umbilical cord to promote oxygenation of the fetus.
✔✔A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage
of labor. Which of the following assessment findings should the nurse report to the
provider first?
-Expulsion of a blood-tinged mucous plug
-Continuous contraction lasting 2 min
-Pressure on the perineum causing the client to bear down
-Expulsion of clear fluid from the vagina - ✔✔Continuous contraction lasting 2 min -
, A uterus contracting for more than 90 seconds is a sign of tetany and could lead to
uterine rupture, which is the greatest risk to the client at this time. The nurse should
report this finding immediately.
✔✔A nurse is caring for a client who is to undergo an amniotomy. Which of the following
is the priority action by the nurse following the procedure?
-Observe color and consistency of fluid.
-Assess the fetal heart rate pattern.
-Assess the client's temperature.
-Evaluate client for the presence of chills and increased uterine tenderness using
palpation. - ✔✔Assess the fetal heart rate pattern.-
Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as
a result of umbilical cord prolapse or compression. Cord prolapse necessitates an
emergent delivery.
✔✔A nurse is caring for a client who is in active labor and notes late deceleration in the
FHR. Which of the following actions should the nurse take first?
-Apply a fetal scalp electrode.
-Increase the rate of the IV infusion.
-Administer oxygen at 10 L/min via a nonrebreather mask.
-Change the client's position. - ✔✔Change the client's position.-
The first action the nurse should take is to change the client's position in an attempt to
increase blood flow to the fetus.
✔✔A nurse is caring for a client who is in active labor at 39 weeks of gestation. The
nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse
should suspect that the fetus is in which of the following positions?
-Cephalic
-Transverse
-Posterior
-Frank breech - ✔✔Frank breech -
With a frank breech presentation, the fetal heart is generally above the level of the
client's umbilicus.
✔✔A nurse is caring for a client who is in labor and has an epidural anesthesia block.
The client's blood pressure is 80/40 mmHg and the fetal heart rate is 140/min. Which of
the following is the priority nursing action?
-Elevate the client's legs.
-Monitor vital signs every 5 min.
-Notify the provider.
-Place the client in a lateral position. - ✔✔Place the client in a lateral position -
Based on Maslow's hierarchy of needs, the client should be moved to a lateral position
or a pillow placed under one of the client's hips to relieve pressure on the inferior vena
cava and improve the blood pressure.
ANSWERS AND QUESTIONS SET A+
✔✔A nurse is caring for a client following an amniotomy who is now in the active phase
of the first stage of labor. Which of the following actions should the nurse implement
with this client?
-Maintain the client in the lithotomy position.
-Perform vaginal examinations frequently.
-Remind the client to bear down with each contraction.
-Encourage the client to empty her bladder every 2 hr. - ✔✔Encourage the client to
empty her bladder every 2 hr. -
A client in labor should be encouraged to empty her bladder every 2 hr. Bladder
distention can impede the descent of the fetus and slow the progression of labor. It can
also contribute to uterine atony after delivery, increasing the client's risk of postpartum
hemorrhage.
✔✔A nurse is caring for a client who is in the first stage of labor. The nurse observes
the umbilical cord protruding from the vagina. Which of the following actions should the
nurse perform first?
-Cover the cord with a sterile, moist saline dressing.
-Prepare the client for an immediate birth.
-Place the client in knee-chest position.
-Insert a gloved hand into the vagina to relieve pressure on the cord. - ✔✔Insert a
gloved hand into the vagina to relieve pressure on the cord. -
This is the first nursing action because it is essential to prevent any pressure on the
umbilical cord to promote oxygenation of the fetus.
✔✔A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage
of labor. Which of the following assessment findings should the nurse report to the
provider first?
-Expulsion of a blood-tinged mucous plug
-Continuous contraction lasting 2 min
-Pressure on the perineum causing the client to bear down
-Expulsion of clear fluid from the vagina - ✔✔Continuous contraction lasting 2 min -
, A uterus contracting for more than 90 seconds is a sign of tetany and could lead to
uterine rupture, which is the greatest risk to the client at this time. The nurse should
report this finding immediately.
✔✔A nurse is caring for a client who is to undergo an amniotomy. Which of the following
is the priority action by the nurse following the procedure?
-Observe color and consistency of fluid.
-Assess the fetal heart rate pattern.
-Assess the client's temperature.
-Evaluate client for the presence of chills and increased uterine tenderness using
palpation. - ✔✔Assess the fetal heart rate pattern.-
Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as
a result of umbilical cord prolapse or compression. Cord prolapse necessitates an
emergent delivery.
✔✔A nurse is caring for a client who is in active labor and notes late deceleration in the
FHR. Which of the following actions should the nurse take first?
-Apply a fetal scalp electrode.
-Increase the rate of the IV infusion.
-Administer oxygen at 10 L/min via a nonrebreather mask.
-Change the client's position. - ✔✔Change the client's position.-
The first action the nurse should take is to change the client's position in an attempt to
increase blood flow to the fetus.
✔✔A nurse is caring for a client who is in active labor at 39 weeks of gestation. The
nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse
should suspect that the fetus is in which of the following positions?
-Cephalic
-Transverse
-Posterior
-Frank breech - ✔✔Frank breech -
With a frank breech presentation, the fetal heart is generally above the level of the
client's umbilicus.
✔✔A nurse is caring for a client who is in labor and has an epidural anesthesia block.
The client's blood pressure is 80/40 mmHg and the fetal heart rate is 140/min. Which of
the following is the priority nursing action?
-Elevate the client's legs.
-Monitor vital signs every 5 min.
-Notify the provider.
-Place the client in a lateral position. - ✔✔Place the client in a lateral position -
Based on Maslow's hierarchy of needs, the client should be moved to a lateral position
or a pillow placed under one of the client's hips to relieve pressure on the inferior vena
cava and improve the blood pressure.
