ATI N3610 Exam With complete solutions
latest version
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?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina - ANSWER- B. Continuous contraction
lasting 2 min
i: 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 providing teaching about nutrition to a client at her first prenatal visit.
Which of the following statements by the nurse should be included in the
teaching?
A. "You will need to increase your calcium intake during breastfeeding."
B. "Prenatal vitamins will meet your need for increased vitamin D during
pregnancy."
C. "Vitamin E requirements decline during pregnancy due to the increase in body
fat."
D. "You will need to double your intake of iron during pregnancy." - ANSWER- D.
"You will need to double your intake of iron during pregnancy."
i: During pregnancy, the need for iron increases to allow transfer of the
appropriate amounts to the fetus and to support expansion of the client's red
blood cell volume.
,A nurse is teaching about fetal development to a group of clients in the antenatal
clinic. Which of the following statements should the nurse include in the
teaching?
A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
B. "The sex of the baby is determined by week 8 of pregnancy."
C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of
pregnancy."
D. "You will first feel your baby move in week 24 of pregnancy." - ANSWER- A.
"The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
i: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of
gestation.
A nurse on the labor and delivery unit is caring for a client following a vaginal
examination by the provider which is documented as: -1. Which of the following
interpretations of this finding should the nurse make?
A. The presenting part is 1cm above the ischial spines.
B. The presenting art is 1cm below the ischial spines.
C. The cervix is 1cm dilated.
D. The cervix is effaced 1cm. - ANSWER- A. The presenting part is 1cm above the
ischial spines.
i: Station is the relation of the presenting part to the ischial spines of the maternal
pelvis and is measured in centimeters above, below, or at the level of the spines.
If the station is minus 1, then the presenting part is 1cm above the ischial spines.
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation
and scheduled for an amniocentesis. The client asks why she is having an
ultrasound prior to the procedure. Which of the following is an appropriate
response by the nurse?
A. "This will determine is there is more than one fetus."
B. "It is useful for estimating fetal age."
C. "It assists in identifying the location of the placenta and fetus."
D. "This is a screening tool for spina bifida." - ANSWER- C. "It assists in
identifying the location of the placenta and fetus."
i: Identifying the positions of the fetus, placenta, and amniotic fluid pockets
immediately prior to the amniocentesis increases the safety of this test by
assisting with correct placement of the needle.
, A nurse on a labor unit is admitting a client who reports painful contractions. The
nurse determines that the contractions have a durtiong of 1min and a frequency
of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal
heart rate 128/min, and maternal blood pressure 92/54mmHg. 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. - ANSWER- B. Position the client with one hip elevated.
i: Based on Maslow's hierarchy of needs, the client's need for an adequate blood
pressure to perfuse herself and her fetus is a physiological need that requires
immediate intervention. Supine hypotension is a frequent cause of low blood
pressure in clients who are pregnant. By turning the client on her side and
retaking her blood pressure, the nurse is attempting to correct the low blood
pressure and reassess.
A nurse is caring for a group of clients on an intrapartum unit. Which of the
following findings should be reported to the provider immediately?
A. A tearful client who is at 32 weeks of gestation and is experiencing irregular,
frequent contractions.
B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine
tremors.
C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+
patellar reflexes.
D. A client who has a diagnosis of preeclampsia reports epigastric pain and
unresolved headache. - ANSWER- D. A client who has a diagnosis of
preeclampsia reports epigastric pain and unresolved headache.
i: These findings indicate that the client's condition is worsening and are signs of
severe preeclampsia. They should be reported to the provider immediately. Other
manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg
or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred
vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right
upper-quadrant pain.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor.
The client has 6cm of cervical dilation and 100% cervical effacement. The nurse
obtains the client's blood pressure reading as 82/52mmHg. Which of the following
nursing interventions should the nurse perform?
latest version
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?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina - ANSWER- B. Continuous contraction
lasting 2 min
i: 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 providing teaching about nutrition to a client at her first prenatal visit.
Which of the following statements by the nurse should be included in the
teaching?
A. "You will need to increase your calcium intake during breastfeeding."
B. "Prenatal vitamins will meet your need for increased vitamin D during
pregnancy."
C. "Vitamin E requirements decline during pregnancy due to the increase in body
fat."
D. "You will need to double your intake of iron during pregnancy." - ANSWER- D.
"You will need to double your intake of iron during pregnancy."
i: During pregnancy, the need for iron increases to allow transfer of the
appropriate amounts to the fetus and to support expansion of the client's red
blood cell volume.
,A nurse is teaching about fetal development to a group of clients in the antenatal
clinic. Which of the following statements should the nurse include in the
teaching?
A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
B. "The sex of the baby is determined by week 8 of pregnancy."
C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of
pregnancy."
D. "You will first feel your baby move in week 24 of pregnancy." - ANSWER- A.
"The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
i: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of
gestation.
A nurse on the labor and delivery unit is caring for a client following a vaginal
examination by the provider which is documented as: -1. Which of the following
interpretations of this finding should the nurse make?
A. The presenting part is 1cm above the ischial spines.
B. The presenting art is 1cm below the ischial spines.
C. The cervix is 1cm dilated.
D. The cervix is effaced 1cm. - ANSWER- A. The presenting part is 1cm above the
ischial spines.
i: Station is the relation of the presenting part to the ischial spines of the maternal
pelvis and is measured in centimeters above, below, or at the level of the spines.
If the station is minus 1, then the presenting part is 1cm above the ischial spines.
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation
and scheduled for an amniocentesis. The client asks why she is having an
ultrasound prior to the procedure. Which of the following is an appropriate
response by the nurse?
A. "This will determine is there is more than one fetus."
B. "It is useful for estimating fetal age."
C. "It assists in identifying the location of the placenta and fetus."
D. "This is a screening tool for spina bifida." - ANSWER- C. "It assists in
identifying the location of the placenta and fetus."
i: Identifying the positions of the fetus, placenta, and amniotic fluid pockets
immediately prior to the amniocentesis increases the safety of this test by
assisting with correct placement of the needle.
, A nurse on a labor unit is admitting a client who reports painful contractions. The
nurse determines that the contractions have a durtiong of 1min and a frequency
of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal
heart rate 128/min, and maternal blood pressure 92/54mmHg. 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. - ANSWER- B. Position the client with one hip elevated.
i: Based on Maslow's hierarchy of needs, the client's need for an adequate blood
pressure to perfuse herself and her fetus is a physiological need that requires
immediate intervention. Supine hypotension is a frequent cause of low blood
pressure in clients who are pregnant. By turning the client on her side and
retaking her blood pressure, the nurse is attempting to correct the low blood
pressure and reassess.
A nurse is caring for a group of clients on an intrapartum unit. Which of the
following findings should be reported to the provider immediately?
A. A tearful client who is at 32 weeks of gestation and is experiencing irregular,
frequent contractions.
B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine
tremors.
C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+
patellar reflexes.
D. A client who has a diagnosis of preeclampsia reports epigastric pain and
unresolved headache. - ANSWER- D. A client who has a diagnosis of
preeclampsia reports epigastric pain and unresolved headache.
i: These findings indicate that the client's condition is worsening and are signs of
severe preeclampsia. They should be reported to the provider immediately. Other
manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg
or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred
vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right
upper-quadrant pain.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor.
The client has 6cm of cervical dilation and 100% cervical effacement. The nurse
obtains the client's blood pressure reading as 82/52mmHg. Which of the following
nursing interventions should the nurse perform?
