C. Transition phase
D. Latent Phase - ....ANSWER...Transition phase
A nurse is assisting with the care for a client who is at40 weeks of gestation and
experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam by the
registered nurse reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station.
ATI PN MATERNITY PROCTORED (BRAND Theclient asks for pain medication. Which of the following actions should the nurse
prepare to take? (Select all that apply)
NEW!!) TEST BANK 200 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH A. Encourage use of patterned breathing techniquesB. Insert an indwelling urinary
catheter
RATIONALES (VERIFIED ANSWERS) C. Administer opioid analgesic medicationD. Suggest application of
cold
|ALREADY GRADED A+ E. Provide ice chips - ....ANSWER...1. Encourage use ofpatterned breathing techniques
2. Administer opioid analgesic medication3. Suggest application of
cold
A nurse is reinforcing teaching with a client who is inlabor about an episiotomy. Which of
the following information should the nurse include?
A nurse is reinforcing discharge teaching with a clientwho has premature rupture of
membranes at 26 weeks of gestation. Which of the following instructions should the A. An episiotomy is a perineal tear that is createdwhile pushing during labor
nurse include? B. A fourth degree episiotomy extends into the rectalarea
C. An episiotomy is an incision that is made by theprovider to facilitate
A. Use a condom with sexual intercourse delivery of the fetus
B. Avoid bubble bath solution when take a tub bath C. Wipe from the back to the
front when performingperineal hygiene
D. Keep a daily record of fetal kick counts -
....ANSWER...Keep a daily record of fetal kick counts
A nurse is assisting with the care for a client who is inactive labor, irritable, and
reports the urge to have a bowel movement. The client vomits and states, "I've had
enough. I can't do this anymore." Which of the following stages of labor is the client
experiencing?
A. Second stageB. Fourth
Stage
, A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse.
D. A mediolateral episiotomy is easier to repair than amedian episiotomy - Which of thefollowing statements should the nurse include?
....ANSWER...An episiotomy is anincision that is made by the provider to facilitate delivery
of the fetus
A. "Count the fetal heart rate for 15 seconds to determine the baseline."
A nurse is assisting with the care for a client who is at42 weeks of gestation and is
having an ultrasound.
B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the
first stage of labor." C. "Count the fetal heart rate after a contraction to determine
For which of the following conditions should the nurseprepare for an autoinfusion?
baseline changes."
(Select all that apply)
D. "Auscultate the fetal heart rate every 30 minutes during the second stage of
labor." -
A. OligohydramniosB. ....ANSWER..."Count the fetal heart rate after a contraction to determine
Hydramnios baseline changes."
C. Fetal cord compressionD. Hydration
E. Fetal immaturity - ....ANSWER ............................................ 1. Oligohydramnios
A nurse is reinforcing teaching with a client about thebenefits of internal fetal heart
2. Fetal cord compression
monitoring. Which of the following statements should the nurse include? (select all that
apply)
A nurse is assisting with the care of a client in activelabor. The nurse observes clear
fluid and a loop of pulsating umbilical cord outside the client's vagina.
Which of the following actions should the nurseperform first? A. "It is considered a noninvasive procedure."
B. "It can detect abnormal fetal heart tones early." C. "It can determine the
A. Place the client in the Trendelenburg positionB. Apply finger pressure to amount of amniotic fluid youhave."
the presenting part D. "It allows for accurate readings with maternalmovement."
C. Administer oxygen at 10 L/min via a nonrebreatherD. Call for assistance - E. "It can measure uterine contraction intensity." -
....ANSWER...Call for assistance ....ANSWER...1. "It can detect abnormal fetal hearttones early."
2. "It allows for accurate readings with maternalmovement."
, A. Apply palms of both hands to sides of uterus.B. Palpate the fundus of the
3. "It can measure uterine contraction intensity." uterus
C. Grasp lower uterine segment between thumb andfingers
A nurse is assisting in the care of a client who is inactive labor. The nurse notes D. Stand facing client's feet with fingertips outlining cephalic prominence -
tachycardia on the external fetal monitor tracing. Which of the followingconditions ....ANSWER...Palpate the fundusof the uterus
should the nurse identify as a potential cause of the heart rate?
A nurse is checking the fundus of a client who is 2 days postpartum and observes the
perineal pad for lochia. The pad is saturated approximately 12 cm withlochia that is
A. Maternal fever bright red and contains small clots.
B. Fetal heart failure Which of the following findings should the nursedocument in the client's
medical record?
C. Maternal hypoglycemia
D. Fetal head compression - ....ANSWER...Maternalfever A. Moderate lochia rubra B. Excessive
lochia serosaC. Light lochia rubra
A nurse is assisting with caring for a client who is in labor and observes late D. Scant lochia serosa - ....ANSWER...Moderate lochiarubra
decelerations on the electronic fetal monitor. Which of the following is thefirst action
the nurse should identify that the registered nurse should take? During ambulation to the bathroom, a postpartum client experiences a gush of dark red
blood that soonstops. On data collection, a nurse finds the uterus to be firm, midline,
A. Assist the client into the left-lateral positionB. Apply a fetal scalp and at the level of the umbilicus.
electrode Which of the following findings should the nurseinterpret this data as being?
C. Insert an IV catheter
D. Perform a vaginal exam - ....ANSWER...Assist theclient into the left-lateral position
A. Evidence of a possible vaginal hematoma
A nurse is assisting with performing Leopold maneuvers on a client who is in labor. Which B. An indication of a cervical or perineal lacerationC. A normal postural discharge
of the following techniques should the nurse use to identifythe fetal lie? of lochia
, D. Abnormally excessive lochia rubra flow - Which of the following information should the nurseinclude? (select all that apply)
....ANSWER...A normal postural discharge of lochia
A nurse is reinforcing postpartum discharge teachingto a client who had no immunity
A. Use a perineal squeeze bottle to cleanse theperineum
to varicella and was given the varicella vaccine. Which of the following statements by the B. Sit on the perineum while resting in bed
client indicates understanding?
C. Apply a topical anesthetic cream or spray to theperineum
D. Wipe the perineum thoroughly with a back and forthmotion
A. "I will need to use contraception for 3 monthsbefore considering
pregnancy." E. Apply cold or ice packs to the perineum -
....ANSWER...1. Use a perineal squeeze bottle tocleanse the perineum
B. "I need a second vaccination at my postpartumvisit."
2. Apply a topical anesthetic cream or spray to theperineum
C. "I was given the vaccine because my baby is O-positibe
3. Apply cold or ice packs to the perineum
D. "I will be tested in 3 months to see if I have developed immunity." - ....ANSWER..."I
need a secondvaccination at my postpartum visit."
COMPLICATIONS OF THE POSTPARTUM PERIOD -
....ANSWER...
A nurse is reinforcing discharge instructions for a client. At 4 weeks postpartum, the
client should contact the provider for which of the following clientfindings?
A nurse is contributing to the plan of care for a clientwho is postpartum and has
thrombophlebitis. Which ofthe following nursing interventions should the nurse
A. Scant, nonodorous white vaginal dischargeB. Uterine cramping during recommend?
breastfeeding
C. Sore nipple with cracks and fissures
D. Decreased response with sexual activity - A. Apply cold compresses to the affected extremityB. Massage the affected
....ANSWER...Sore nipple with cracks and fissures extremity
C. Allow the client to ambulate D. Measure leg
circumferences -
A nurse is preparing to reinforce education to a clientwho is 2 hr postpartum and has ....ANSWER...Measure leg circumferences
perineal laceration.
D. Latent Phase - ....ANSWER...Transition phase
A nurse is assisting with the care for a client who is at40 weeks of gestation and
experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam by the
registered nurse reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station.
ATI PN MATERNITY PROCTORED (BRAND Theclient asks for pain medication. Which of the following actions should the nurse
prepare to take? (Select all that apply)
NEW!!) TEST BANK 200 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH A. Encourage use of patterned breathing techniquesB. Insert an indwelling urinary
catheter
RATIONALES (VERIFIED ANSWERS) C. Administer opioid analgesic medicationD. Suggest application of
cold
|ALREADY GRADED A+ E. Provide ice chips - ....ANSWER...1. Encourage use ofpatterned breathing techniques
2. Administer opioid analgesic medication3. Suggest application of
cold
A nurse is reinforcing teaching with a client who is inlabor about an episiotomy. Which of
the following information should the nurse include?
A nurse is reinforcing discharge teaching with a clientwho has premature rupture of
membranes at 26 weeks of gestation. Which of the following instructions should the A. An episiotomy is a perineal tear that is createdwhile pushing during labor
nurse include? B. A fourth degree episiotomy extends into the rectalarea
C. An episiotomy is an incision that is made by theprovider to facilitate
A. Use a condom with sexual intercourse delivery of the fetus
B. Avoid bubble bath solution when take a tub bath C. Wipe from the back to the
front when performingperineal hygiene
D. Keep a daily record of fetal kick counts -
....ANSWER...Keep a daily record of fetal kick counts
A nurse is assisting with the care for a client who is inactive labor, irritable, and
reports the urge to have a bowel movement. The client vomits and states, "I've had
enough. I can't do this anymore." Which of the following stages of labor is the client
experiencing?
A. Second stageB. Fourth
Stage
, A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse.
D. A mediolateral episiotomy is easier to repair than amedian episiotomy - Which of thefollowing statements should the nurse include?
....ANSWER...An episiotomy is anincision that is made by the provider to facilitate delivery
of the fetus
A. "Count the fetal heart rate for 15 seconds to determine the baseline."
A nurse is assisting with the care for a client who is at42 weeks of gestation and is
having an ultrasound.
B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the
first stage of labor." C. "Count the fetal heart rate after a contraction to determine
For which of the following conditions should the nurseprepare for an autoinfusion?
baseline changes."
(Select all that apply)
D. "Auscultate the fetal heart rate every 30 minutes during the second stage of
labor." -
A. OligohydramniosB. ....ANSWER..."Count the fetal heart rate after a contraction to determine
Hydramnios baseline changes."
C. Fetal cord compressionD. Hydration
E. Fetal immaturity - ....ANSWER ............................................ 1. Oligohydramnios
A nurse is reinforcing teaching with a client about thebenefits of internal fetal heart
2. Fetal cord compression
monitoring. Which of the following statements should the nurse include? (select all that
apply)
A nurse is assisting with the care of a client in activelabor. The nurse observes clear
fluid and a loop of pulsating umbilical cord outside the client's vagina.
Which of the following actions should the nurseperform first? A. "It is considered a noninvasive procedure."
B. "It can detect abnormal fetal heart tones early." C. "It can determine the
A. Place the client in the Trendelenburg positionB. Apply finger pressure to amount of amniotic fluid youhave."
the presenting part D. "It allows for accurate readings with maternalmovement."
C. Administer oxygen at 10 L/min via a nonrebreatherD. Call for assistance - E. "It can measure uterine contraction intensity." -
....ANSWER...Call for assistance ....ANSWER...1. "It can detect abnormal fetal hearttones early."
2. "It allows for accurate readings with maternalmovement."
, A. Apply palms of both hands to sides of uterus.B. Palpate the fundus of the
3. "It can measure uterine contraction intensity." uterus
C. Grasp lower uterine segment between thumb andfingers
A nurse is assisting in the care of a client who is inactive labor. The nurse notes D. Stand facing client's feet with fingertips outlining cephalic prominence -
tachycardia on the external fetal monitor tracing. Which of the followingconditions ....ANSWER...Palpate the fundusof the uterus
should the nurse identify as a potential cause of the heart rate?
A nurse is checking the fundus of a client who is 2 days postpartum and observes the
perineal pad for lochia. The pad is saturated approximately 12 cm withlochia that is
A. Maternal fever bright red and contains small clots.
B. Fetal heart failure Which of the following findings should the nursedocument in the client's
medical record?
C. Maternal hypoglycemia
D. Fetal head compression - ....ANSWER...Maternalfever A. Moderate lochia rubra B. Excessive
lochia serosaC. Light lochia rubra
A nurse is assisting with caring for a client who is in labor and observes late D. Scant lochia serosa - ....ANSWER...Moderate lochiarubra
decelerations on the electronic fetal monitor. Which of the following is thefirst action
the nurse should identify that the registered nurse should take? During ambulation to the bathroom, a postpartum client experiences a gush of dark red
blood that soonstops. On data collection, a nurse finds the uterus to be firm, midline,
A. Assist the client into the left-lateral positionB. Apply a fetal scalp and at the level of the umbilicus.
electrode Which of the following findings should the nurseinterpret this data as being?
C. Insert an IV catheter
D. Perform a vaginal exam - ....ANSWER...Assist theclient into the left-lateral position
A. Evidence of a possible vaginal hematoma
A nurse is assisting with performing Leopold maneuvers on a client who is in labor. Which B. An indication of a cervical or perineal lacerationC. A normal postural discharge
of the following techniques should the nurse use to identifythe fetal lie? of lochia
, D. Abnormally excessive lochia rubra flow - Which of the following information should the nurseinclude? (select all that apply)
....ANSWER...A normal postural discharge of lochia
A nurse is reinforcing postpartum discharge teachingto a client who had no immunity
A. Use a perineal squeeze bottle to cleanse theperineum
to varicella and was given the varicella vaccine. Which of the following statements by the B. Sit on the perineum while resting in bed
client indicates understanding?
C. Apply a topical anesthetic cream or spray to theperineum
D. Wipe the perineum thoroughly with a back and forthmotion
A. "I will need to use contraception for 3 monthsbefore considering
pregnancy." E. Apply cold or ice packs to the perineum -
....ANSWER...1. Use a perineal squeeze bottle tocleanse the perineum
B. "I need a second vaccination at my postpartumvisit."
2. Apply a topical anesthetic cream or spray to theperineum
C. "I was given the vaccine because my baby is O-positibe
3. Apply cold or ice packs to the perineum
D. "I will be tested in 3 months to see if I have developed immunity." - ....ANSWER..."I
need a secondvaccination at my postpartum visit."
COMPLICATIONS OF THE POSTPARTUM PERIOD -
....ANSWER...
A nurse is reinforcing discharge instructions for a client. At 4 weeks postpartum, the
client should contact the provider for which of the following clientfindings?
A nurse is contributing to the plan of care for a clientwho is postpartum and has
thrombophlebitis. Which ofthe following nursing interventions should the nurse
A. Scant, nonodorous white vaginal dischargeB. Uterine cramping during recommend?
breastfeeding
C. Sore nipple with cracks and fissures
D. Decreased response with sexual activity - A. Apply cold compresses to the affected extremityB. Massage the affected
....ANSWER...Sore nipple with cracks and fissures extremity
C. Allow the client to ambulate D. Measure leg
circumferences -
A nurse is preparing to reinforce education to a clientwho is 2 hr postpartum and has ....ANSWER...Measure leg circumferences
perineal laceration.
