ATI Quiz 1

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during the test. Which of the following should the nurse include? Select all that apply. a. Fetal breathing b. Fetal motion c. Fetal neck translucency d. Amniotic fluid volume e. Fetal gender

a, b,d

5 variable we look at when doing biophysical profil are:

a. Result of NST b. Movement c. tone d. get breathing movement c. Amniotic fluid (a score of 8-10 is OKAY!)

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? A. 3cm above the umbilicus B. Slightly above the umbilicus C. Slightly below the umbilicus D. 3cm below the umbilicus

b

a nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? a. Decreased vaginal discharge b. A surge of energy c. Urinary retention d. Wt gain of 0.5 to 1.5 kg

b

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.

b Rational: 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 admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9C/102F. Besides notifying the provider, which of the following is the appropriate nursing action? A. Recheck the client's temperature in 4 hr. B. Administer glucocorticoids intramuscularly. C. Assess the odor of the amniotic fluid. D. Prepare the client for emergency cesarean section.

c

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? a. "will occur during the last trimester of pregnancy." b. "will happen by the end of the first trimester of pregnancy." c. "will occur between the fourth and fifth months of pregnancy." d. "will happen once the uterus begins to rise out of the pelvis."

c

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? A. Apply fundal pressure. B. Observe for the presence of a nuchal cord. C. Observe for crowning. D. Prepare to administer oxytocin.

c

A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? a. "you should not receive the rubella vaccine while breastfeeding." b. "you should receive a vericella vaccine before you deliver." c. "You can receive an influenza vaccination during pregnancy." d. "You cannot receive Tdap vaccine until after your delivery."

c

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? A. The fetal head is in the left occiput posterior position. B. The largest fetal diameter has passed through the pelvic outlet. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

d

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following action should the nurse take? a. Have the client stand at the bedside with her arms at her side." b. Administer a 500 ml bolus of 5% dextrose in water prior to induction c. Inform the client the anesthetic effect will last for approximately 6 hr. d. Obtain a 30 min electronic fetal monitoring strip prior to induction.

d

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? A. "I should drink about 2 liters of fluid each day." B. "I should not drink alcoholic beverages during my pregnancy." C. "I can have a moderate amount of caffeine daily." D. "I should increase my calcium intake to 1,500mg per day."

d Rational: A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass.

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A. Left lower B. Right lower C. Left upper D. Right upper

d rational: Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant.