ATI Custom: Missing clinicals day 2
A nurse is caring for a client who is in labor and has an epidural anesthesia block.
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The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min.
Which of the following is the priority nursing action? - -Place the client in a
lateral position
Rationale: 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.
A nurse is performing Leopold maneuvers on a client who is in labor and determines
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the fetus is in an RSA position. Which of the following fetal presentations should the
nurse document in the client's medical record? - -Breech
Rationale: An RSA position indicates that the body part of the fetus that is closest to
the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part,
which is classified as a breech presentation.
A nurse is caring for a client who is in labor and assists the provider who performs an
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amniotomy. Which of the following is the priority action by the nurse following the
procedure? - -Assess the fetal heart rate.
Rationale: The fetal heart rate should be assessed before and immediately after the
amniotomy to detect any changes.
A nurse in a clinic is reviewing the medical records of a group of clients who are
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pregnant. The nurse should anticipate the provider will order a maternal serum
alpha-fetoprotein (MSAFP) screening for which of the following clients? - -All of
the clients
Rationale: MSAFP is a screening tool to detect open spinal and abdominal wall
defects in the fetus. This maternal blood test is recommended for all pregnant
woman.
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A nurse is caring for a newborn and auscultates an apical heart rate of 130/min.
Which of the following actions should the nurse take? - -Document this as an
expected finding.
Rationale: The expected reference range for an apical pulse in a newborn who is
awake is 120 to 160/min. The nurse should document this as an expected finding.
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A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory
rates is within the expected reference range for a newborn? - -48/min
, Rationale: The expected reference range for a newborn's resting respiratory rate is
30 to 60/min.
A nurse is caring for a client who is at 32 weeks of gestation. Which of the following
provider prescriptions should the nurse plan to implement? For each potential
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provider's prescription, click to specify if the potential prescription is anticipated,
nonessential, or contraindicated for the client. - -- Collecting a urine specimen
for culture and sensitivity is nonessential.
The nurse should collect a urine specimen for culture and sensitivity if the client
presents with manifestations of a UTI.
- Administer magnesium sulfate 4 g IV bolus is anticipated.
This client is preeclamptic and has manifestations of CNS irritability including 3+
deep tendon reflexes, headache, and blurred vision. These manifestations place the
client at a greater risk for seizure activity; therefore, the provider should prescribe a
magnesium sulfate 4 g IV bolus, followed by a 2 g/hr maintenance dose.
- Tell the client to lie in a supine position is contraindicated.
The nurse should encourage the client to lay in a side-lying position. A side-lying
position increases uteroplacental blood flow and decreases blood pressure.
- Monitor blood pressure and respiratory status every 15 min is anticipated.
To evaluate the effectiveness of therapy the nurse should anticipate the provider to
prescribe monitoring the client's blood pressure every 15 to 30 min.
A nurse is reinforcing teaching about contraceptive methods with a client. Which of
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the following should the nurse recognize as a contraindication for diaphragm use? -
-The client has pelvic relaxation
Rationale: Pelvic relaxation and large cystocele are contraindications for diaphragm
use.
A nurse is caring for a client who is in labor and has an external fetal monitor. The
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nurse observes late decelerations on the monitor strip and interprets them as
indicating which of the following? - -Uteroplacental insufficiency
Rationale:
The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late
decelerations are the result of uteroplacental insufficiency and the fetus becomes
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