ATI Maternal-Child Nursing OB Detailed Answer Key 2023/2024.

ATI Maternal-Child Nursing OB Answers 2023/2024. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? A. Two veins and one artery Rationale: This is not the correct combination of vessels. B. One artery and one vein Rationale: This is not the correct combination of vessels. C. Two arteries and one vein Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. D. Two arteries and two veins Rationale: This is not the correct combination of vessels. 9. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A. A male condom Rationale: This method of contraception has 11 to 16 failures for every 100 users. B. An intrauterine device (IUD) Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most Created on:11/29/2018 Page 4 lOMoARcPSD| Detailed Answer Key medical reliable methods of contraception. C. An oral contraceptive Rationale: This method of contraception has about 8 failures for every 100 users, due to failure to take pill consistently and decreased efficacy when taken with certain medications. D. A diaphragm with spermicide. Rationale: This method of contraception has about 16 failures for every 100 users during the first year of use. 10.A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. It does not indicate the presence or absence of a rubella infection. B. The client is immune to the rubella virus. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. C. The client requires a rubella vaccination at this time. Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. D. The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. 11.A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? A. Insert an indwelling urinary catheter. Rationale: An indwelling urinary catheter can be inserted in the delivery room just prior to delivery. This is not the priority nursing action. B. Initiate IV access. Rationale: Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops. Created on:11/29/2018 Page 5 lOMoARcPSD| Detailed Answer Key medical C. Witness the signature for informed consent for surgery. Rationale: Rationale C. This is not the nurse's priority action at this time. A family member can sign the consent form if needed. D. Prepare the abdominal and perineal areas. Rationale: Skin preparation can be delayed until just prior to a cesarean delivery. This is no the priority nursing action. 12.A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? A. Rapid decline in human chorionic gonadotropin (hCG) levels Rationale: A client who has a hydatidiform mole usually has an elevated serum hCG level. B. Profuse, clear vaginal discharge Rationale: A client who has a hydatidiform mole often has vaginal bleeding later in the pregnancy. This discharge can be dark brown, bright red, scant, or profuse. C. Irregular fetal heart rate Rationale: When a client has a hydatidiform mole, fetal heart tones are not heard since there is no developing fetus. D. Excessive uterine enlargement Rationale: A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia. 13.A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? A. "I will call your primary care provider to report your concerns." Rationale: This is an inappropriate response by the nurse because it does not address the client's feelings of concern. B. "I will take your baby to the nursery for further examination." Rationale: It is not necessary for the nurse to complete additional examination of the newborn. This also does not address the client’s concerns. C. "This occurs because newborns lack muscle control to regulate eye movement." Rationale: Created on:11/29/2018 Page 6 lOMoARcPSD| Detailed Answer Key medical This addresses the client’s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. D. "This is a concern, but strabismus is easily treated with patching." Rationale: This is an inappropriate statement by the nurse because it offers unwarranted reassurance. The nurse is making an assumption that that should be addressed by the provider. 14.A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? A. Immediately report the situation to the client's provider and prepare the client for induction of labor. Rationale: The fetus might not be moving because it is asleep, or there might be another benign reason. B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. Rationale: Having the client walk is not likely to promote fetal movement. C. Offer the client a snack of orange juice and crackers. Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement. D. Turn the client onto her left side. Rationale: Turning the client onto her left side increases the placental perfusion of oxygen to the fetus, but the FHR of 130 to 150/min is not indicative of fetal distress. 15.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 min and a frequency of 3 min. 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. Rationale: Calling the provider may be appropriate; however, this is not the priority intervention. B. Position the client with one hip elevated. Rationale: 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. C. Ask the client if she needs pain medication. Rationale: Created on:11/29/2018 Page 7 lOMoARcPSD| Detailed Answer Key medical The client's comfort should be addressed; however, this is not the priority intervention. D. Have the client void. Rationale: The client should be encouraged to empty her bladder every 2 hr during labor; however, this is not the priority intervention. 16.A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membranes Rationale: The membranes can rupture spontaneously long before the onset of labor. B. Changes in the cervix Rationale: Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor. C. Station of the presenting part Rationale: A client who is a primigravida will typically engage before labor and can enter labor at -1, 0, or even +1 station. D. Pattern of contractions Rationale: A client can have regular contractions for a significant period of time prior to the onset of true labor. 17.A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? A. Temperature Rationale: Although the use of magnesium sulfate in a client experiencing preterm labor can result in hypothermia, this assessment is not the nurse’s priority assessment. B. Fetal heart rate (FHR) Rationale: It is important to monitor the FHR of any client experiencing labor; however, this assessment is not the nurse’s priority assessment. C. Bowel sounds Rationale: Although the use of magnesium sulfate in a client experiencing preterm labor can result in ileus, this assessment is not the nurse’s priority assessment. D. Respiratory rate Rationale: Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous Created on:11/29/2018 Page 8 lOMoARcPSD| Detailed Answer Key medical system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate. 18.A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn’s plan of care? A. Observe for meconium in respiratory secretions. Rationale: When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery.