Test Bank for NUR404/ Maternity ATI Proctored Exam
Questions and Correct Detailed Answers/ Updated 2024
Rated A+
The nurse is assessing a client in labor. On which complication of laborers identified within the 2030
National Health Goals will the nurse focus?
A. uterine rupture
B. prolapsed fetal cord
C. hypotonic contractions
D. hypertonic contractions - ANSWER - A
Nurses can help the nation achieve the 2020 National Health Goals for complications of labor by being
alert to the preliminary symptoms of uterine rupture, which accounts for a substantial number of
maternal deaths during labor. Hypotonic and hypertonic contractions and prolapsed fetal cord are not
identified as specific complications of labor within the 2020 National Health Goals.
An infant was born after a face presentation. When selecting a nursing diagnosis for the newborn, which
body system does the nurse identify as a priority?
A. respiratory
B. genitourinary
C. cardiovascular
D. gastrointestinal - ANSWER - A
Babies born after a face presentation have a great deal of facial edema and maybe purple from bruising.
The infant must be observed closely for a patent airway, which is the priority. A face presentation does
not affect the cardiovascular or genitourinary systems. If lipedema is severe, the newborn might need
gavage feedings until the edema subsides and sucking can occur.
pg. 1
,The fetus of a pregnant client is in a breech presentation. Where will the nurse auscultate fetal heart
sounds?
A. low in the abdomen
B. left lateral abdomen
C. high in the abdomen
D. right lateral abdomen - ANSWER - C
With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In a breech
presentation, fetal heart sounds will not be heard low in the abdomen or over the left or right lateral
abdominal regions.
A multipara client in labor is having contractions which are 2 minutes apart but rarely over 50 mm Hg in
strength; the resting uterine tone is high, 20 to 25 mm Hg. The client asks what she can do to make
contractions more effective. The nurse's best response is:
A. rest between contractions.
B. request oxytocin to strengthen the contractions.
C. be patient as contractions will strengthen by themselves.
D. ambulate to make the contractions regular. - ANSWER - A
The client's contractions are hypertonic because of the high resting tone. Hypertonic contractions occur
because the uterus is being overstimulated or erratically stimulated. Rest, not activity, is effective in
helping contractions become more productive. Oxytocin is contraindicated. There is no guarantee that
waiting will change the status of the contractions.
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's
best action would be to:
A. assess the rate of flow of the oxytocin infusion.
B. administer oral orange juice for added potassium.
pg. 2
,C. assess her vaginally for full dilation (dilatation).
D. instruct her to breathe in and out rapidly. - ANSWER - A
A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea.
Assessing and slowing the infusion rate will relieve symptoms.
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head
begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:
A. place a hand gently on the fetal head to guide birth.
B. ask her to push with the next contraction so birth is rapid.
C. assess blood pressure and pulse to detect placental bleeding.
D. attach a fetal monitor to determine fetal status. - ANSWER - A
After delivery, a client is diagnosed with placenta succenturiata. For what procedure should the nurse
prepare this client?
A. lavage of the uterus
B. repair of an episiotomy
C. manual removal of accessory lobes
D. emergency resuscitation of the newborn - ANSWER - C
A placenta succenturiata is a placenta that has one or more accessory lobes connected to the main
placenta by blood vessels. This disorder needs to be recognized because the small lobes may be retained
in the uterus after birth, leading to severe maternal hemorrhage. Once the remaining lobes are
recognized and removed from the uterus manually, the uterus will contract with no adverse maternal
effects. Uterine lavage is not a treatment for this disorder. This disorder is not specifically associated with
an episiotomy. No fetal abnormality is associated with this disorder.
The nurse is caring for a client in labor whose fetus is in an occiput posterior position. Which intervention
should the nurse use to reduce this client's discomfort?
pg. 3
, A. Massage the lower back.
B. Place in a prone position.
C. Apply ice packs to the lower back.
D. Place in the Trendelenburg position. - ANSWER - A
Because the fetal head rotates against the sacrum in the occiput posterior position, the client may
experience pressure and pain in the lower back because of sacral nerve compression. Applying counter
pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain. The client does
not need to be placed in the prone or Trendelenburg positions. Ice packs are not indicated to reduce this
pain.
While the placenta is being delivered after labor, a client experiences an amniotic fluid embolism. What
should the nurse do first to help this client?
A. Administer oxygen by nasal cannula.
B. Increase intravenous fluid infusion rate.
C. Put firm pressure on the fundus of the uterus.
D. Tell the client to take short, shallow breaths. - ANSWER - A
The clinical picture of an amniotic fluid embolism is dramatic. The client suddenly experiences sharp
chest pain and is unable to breathe as pulmonary artery constriction occurs. The immediate
management is oxygen administration by face mask or cannula. Intravenous fluids; pressure on the
fundus; or taking short, shallow breaths is not going to help the manifestations of an amniotic fluid
embolism.
A client in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will
be used. What should the nurse do to prepare the client for this type of delivery? Select all that apply.
A. Provide oxygen 2 L via face mask.
B. Validate that the cervix is fully dilated.
C. Determine that the client's bladder is empty.
D. Begin an intravenous infusion of replacement fluid.
pg. 4
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