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ATI LPN Maternity Exam

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Question 1:

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Explanation

The correct answer is Choice D: Contraction lasting 85 seconds.

Choice A rationale: A contraction resting period of 35 seconds is normal and expected during labor. The resting period allows the uterine muscle to relax and replenish its oxygen supply, which is essential for fetal well-being. The resting period also gives the client a chance to rest and cope with the pain of labor. A normal resting period ranges from 30 to 90 seconds, depending on the stage and phase of labor¹².

Choice B rationale: A heart rate of 100/min for a 10-min period is within the normal range for an adult. The normal resting heart rate for an adult is 60 to 100 beats per minute (bpm)³. During labor, the heart rate may increase due to factors such as pain, anxiety, dehydration, fever, or infection. However, a heart rate of 100/min is not considered a sign of distress or complication, unless it is accompanied by other symptoms such as chest pain, shortness of breath, or palpitations⁴⁵.

Choice C rationale: Four contractions in a 10-min period is a normal frequency for labor contractions. The frequency of contractions refers to how often they occur, measured from the beginning of one contraction to the beginning of the next. The normal frequency of contractions varies depending on the stage and phase of labor, but generally ranges from two to five contractions in 10 minutes¹².

Choice D rationale: A contraction lasting 85 seconds is too long and should be reported to the provider. The duration of contractions refers to how long they last, measured from the beginning to the end of one contraction. The normal duration of contractions ranges from 30 to 70 seconds, depending on the stage and phase of labor¹². A contraction lasting longer than 90 seconds is considered a prolonged contraction, which can reduce the blood flow and oxygen supply to the placenta and the fetus, leading to fetal hypoxia and acidosis. Prolonged contractions can also cause uterine rupture, placental abruption, or maternal hemorrhage .


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Question 2:

A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

Explanation

Choice A rationale: Misoprostol is a prostaglandin analog and is contraindicated for use during labor at 32 weeks of gestation as it can lead to uterine hyperstimulation, which may pose a risk to the preterm fetus.
Choice B rationale: Folic acid is a vitamin supplement and is not contraindicated during labor. However, it is typically taken earlier in pregnancy to prevent neural tube defects.
Choice C rationale: Nifedipine is a calcium channel blocker that may be used to suppress preterm labor, and it is not contraindicated at 32 weeks of gestation.
Choice D rationale: Terbutaline is a beta-adrenergic agonist that may be used to relax the uterine smooth muscles and inhibit preterm labor. It is not contraindicated at 32 weeks of gestation.


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Question 3:

A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

Explanation

Choice A rationale: While this is an important action, it is not the first priority immediately after delivery. The priority is to ensure the newborn's breathing and warmth.
Choice B rationale: Assessing the gestational age of the newborn is important but can be done after ensuring the newborn's immediate well-being.
Choice C rationale: This is important for proper identification, but it can be done after the newborn is stabilized.
Choice D rationale: The first action after delivery is to dry the newborn to prevent hypothermia and stimulate breathing. Drying the baby helps remove amniotic fluid and stimulates the baby's reflexes, making it the priority action.


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Question 4:

A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

Explanation

Choice A rationale: An amniocentesis involves inserting a needle through the abdominal wall into the amniotic sac to obtain a sample of amniotic fluid. Emptying the bladder before the procedure reduces the risk of bladder puncture during the process.
Choice B rationale: Fasting is not typically necessary for an amniocentesis. It is generally done on an outpatient basis, and fasting is not required.
Choice C rationale: An enema is not necessary before an amniocentesis and is not part of the standard preparation.
Choice D rationale: While cleanliness is important, this instruction is not specific to an amniocentesis and is not a standard pre-procedure requirement.


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Question 5:

A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?

Explanation

Choice A rationale: Auscultating fetal heart tones in the right upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal back is on the right side of the mother's abdomen, and the fetal head is in the fundal portion of the uterus.
Choice B rationale: During Leopold maneuvers, the nurse palpated a round, firm, movable part in the fundal portion of the uterus. This finding corresponds to the fetal head, which is typically located at the top of the uterus (fundus). Additionally, the nurse palpated a long, smooth surface on the mother's right side. This finding indicates the fetal back, which typically lies along the right side of the mother's abdomen, suggesting that the fetus's back is positioned anteriorly (toward the mother's front). The location of the fetal heart is typically best heard over the back of the fetus. Therefore, the nurse should auscultate the fetal heart tones in the maternal quadrant corresponding to the back of the fetus, which is the left lower quadrant.
Choice C rationale: The information from Leopold maneuvers does not indicate the fetal back is in the right lower quadrant. The nurse should not auscultate fetal heart tones in this area.
Choice D rationale: Auscultating fetal heart tones in the left upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal head is in the fundal portion of the uterus and the fetal back is on the right side of the mother's abdomen. The fetal heart is usually best heard over the back of the fetus, which is not in the left upper quadrant.


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Question 6:

A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?

Explanation

Choice A rationale: Placing the newborn in the Trendelenburg position (head down, feet up) is not recommended in this situation and can potentially cause harm.
Choice B rationale: While saline drops can help clear nasal congestion, the bubbling mucus is coming from the mouth and nose, and suctioning is more appropriate.
Choice C rationale: The bubbling mucus indicates the presence of mucus and amniotic fluid in the baby's airway, which could interfere with breathing. The first action should be to suction the newborn's mouth to clear the airway.
Choice D rationale: Performing deep suctioning with an endotracheal tube is an invasive procedure and is not necessary for clearing mucus from the newborn's mouth and nose.


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Question 7:

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

Explanation

Choice A rationale: The umbilical cord contains three blood vessels: two arteries and one vein. The two arteries carry deoxygenated blood and waste products from the fetus back to the placenta, while the one vein carries oxygenated blood and nutrients from the placenta to the fetus.
Choice B rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins. It contains two arteries and one vein.
Choice C rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins and one artery. It contains two arteries and one vein.
Choice D Rationale: This option is incorrect because the umbilical cord in a newborn does not have only one artery and one vein. It contains two arteries and one vein.


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Question 8:

A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?

Explanation

Choice A rationale:
Primipara refers to a woman who is giving birth for the first time. While being a primipara may have some implications for the birthing process, it is not a cause of the newborn being small for gestational age.
Choice B rationale:
Maternal obesity may have various effects on pregnancy, but it is not specifically a direct cause of the newborn being small for gestational age.
Choice C rationale:
Perinatal asphyxia refers to a lack of oxygen or oxygen deprivation around the time of birth. While this can lead to various health issues for the newborn, it is not a primary cause of being small for gestational age.
Choice D rationale:
Placental insufficiency occurs when the placenta does not function adequately to provide sufficient oxygen and nutrients to the developing fetus. This can result in the newborn being small for gestational age due to restricted growth in the womb.


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Question 9:

A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?

Explanation

Choice A rationale:
A protruding abdomen is not specifically associated with being small for gestational age and can have various other causes in newborns.
Choice B rationale:
A gray umbilical cord is not a typical finding associated with being small for gestational age. Choice C rationale:
Moist skin is not a specific finding associated with being small for gestational age and can be observed in all newborns.
Choice D rationale:
Wide skull sutures are associated with being small for gestational age, as the skull bones may not fully close due to restricted growth in the womb.


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Question 10:

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

Explanation

Choice A rationale:
Maternal gestational diabetes can lead to the newborn being larger than average (macrosomia) or smaller than average (small for gestational age) due to the impact of high blood sugar levels in the mother affecting fetal growth.
Choice B rationale:
Newborn hypoglycemia can be a complication of maternal gestational diabetes, but it is not the focus of this question.
Choice C rationale:
Oligohydramnios refers to decreased amniotic fluid, which can be a complication of various factors, but it is not directly related to maternal gestational diabetes.
Choice D rationale:
Placenta previa is a condition where the placenta partially or completely covers the cervix, which is unrelated to maternal gestational diabetes.


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Question 11:

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

Explanation

Choice A rationale: The umbilical cord contains three blood vessels: two arteries and one vein. The two arteries carry deoxygenated blood and waste products from the fetus back to the placenta, while the one vein carries oxygenated blood and nutrients from the placenta to the fetus.
Choice B rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins. It contains two arteries and one vein.
Choice C rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins and one artery. It contains two arteries and one vein.
Choice D Rationale: This option is incorrect because the umbilical cord in a newborn does not have only one artery and one vein. It contains two arteries and one vein.


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Question 12:

A nurse is collecting data from a client who is at 18 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the previous day. The nurse should use which of the following terms to document this finding?

Explanation

Choice A rationale: The correct term to document this finding is "Quickening." Quickening refers to the first perception of fetal movement by the pregnant woman, usually described as light fluttering or sensation of movement in the abdomen. It is an exciting milestone for pregnant women and often occurs around 18 to 20 weeks of gestation. It is a significant moment as it indicates the woman can feel the baby's movements, signifying the fetus's increasing activity and growth.
Choice B rationale: Ballottement is a physical examination technique used to assess the fetus's position and movement within the amniotic fluid during pregnancy. It involves a gentle tap on the mother's abdomen to feel the fetus bounce or float in the amniotic fluid.
Choice C rationale: Chloasma, also known as the "mask of pregnancy," refers to dark patches of skin that may appear on the face during pregnancy due to hormonal changes. It is not related to the sensation of fetal movement.
Choice D rationale: Lightening, also known as "engagement," is the process in late pregnancy when the baby's head descends into the pelvis, preparing for childbirth. It often occurs a few weeks before labor begins and can result in the mother feeling less pressure on her diaphragm, which may make breathing easier. It is not related to the perception of fetal movement described by the client.


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Question 13:

A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Explanation

Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.


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Question 14:

A nurse is caring for a client who is pregnant and undergoing a nonstress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take?

Explanation

Choice A rationale:
Turning the client onto her left side is a common measure to improve fetal oxygenation and is often used during labor. However, in this scenario, the nurse needs to address the absence of fetal movement during the nonstress test.
Choice B rationale:
Encouraging the client to walk around and then resume monitoring is not appropriate when there is a concern about the absence of fetal movement during the nonstress test.
Choice C rationale:
Vibroacoustic stimulation involves using sound stimulation to elicit fetal movement. If there has been no fetal movement during the nonstress test, this intervention can be used to assess fetal well-being and provoke a response from the fetus.
Choice D rationale:
Preparing the client for induction of labor is not indicated based solely on the absence of fetal movement during a nonstress test. Further assessment and interventions are needed before considering induction.


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Question 15:

A client who is 7 days postpartum calls the provider's office and reports pain, swelling, and redness of her left calf. Besides the client seeing the provider, which of the following interventions should the nurse suggest?

Explanation

Choice A rationale:
Massaging the area is not recommended because the client's symptoms could indicate a possible deep vein thrombosis (DVT), and massaging could dislodge a clot and cause harm.
Choice B rationale:
Applying cold compresses is not recommended if DVT is suspected, as it could potentially worsen the condition.
Choice C rationale:
Flexing the knee while resting is not recommended if DVT is suspected, as it could potentially worsen the condition and increase the risk of a clot traveling to the lungs (pulmonary embolism).
Choice D rationale:
Elevating the leg can help reduce swelling and improve blood flow. However, the client should still see the provider for further evaluation of possible DVT.


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Question 16:

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

Explanation

Choice A rationale:

Administering the hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is not the appropriate treatment for a newborn whose mother is positive for the hepatitis B surface antigen. Immediate intervention is required to prevent transmission.
Choice B rationale:

The newborn of a mother who is positive for the hepatitis B surface antigen should receive hepatitis B immune globulin (HBIG) and the hepatitis B vaccine within 12 hours of birth. HBIG provides passive immunity to the baby while the vaccine stimulates active immunity.
Choice C rationale:

Administering hepatitis B immune globulin for 1 week followed by the hepatitis B vaccine monthly for 6 months is not the correct treatment plan. Immediate intervention is necessary to prevent transmission to the newborn.
Choice D rationale:

Administering the hepatitis B vaccine at 24 hours followed by hepatitis B immune globulin every 12 hours for 3 days is not the appropriate treatment. Hepatitis B immune globulin should be given within 12 hours of birth, not over several days.


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Question 17:

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

Explanation

Choice A rationale:

Newborns of diabetic mothers are at risk of developing hypoglycemia (low blood sugar) after birth, especially if they are large for gestational age like the newborn in this scenario.
Choice B rationale:

Hypercalcemia (high blood calcium levels) is not a typical concern in newborns of diabetic mothers, and it is not directly related to the baby's size.
Choice C rationale:

Decreased REC (Respiratory Exchange Capacity) is not a common issue in this scenario, and it is not related to the baby's size or the mother's diabetes.


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Question 18:

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Explanation

Choice A rationale:

Encouraging the client to nurse more frequently will help with milk production and breastfeeding but is not the priority action based on the data provided.

Choice B rationale:

A temperature elevation above 38°C (100.4°F) in the postpartum period can indicate infection. The nurse should report this finding to the healthcare provider for further evaluation and management.

Choice C rationale:

Increasing IV fluids is not indicated based on the data provided. The client's vital signs are within the expected range for the postpartum period.

Choice D rationale:

Emptying the bladder can be important to prevent bladder distention and discomfort, but it is not the priority action based on the data provided.


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Question 19:

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

Explanation

Choice A rationale:
Placing only part of the nipple in the baby's mouth may result in an ineffective latch, leading to breastfeeding difficulties.
Choice B rationale:
Placing only the nipple and some of the areola in the baby's mouth may also result in an ineffective latch and discomfort for the mother.
Choice C rationale:
The nurse's response is appropriate. The newborn should take in not only the nipple and the areola but also some breast tissue beyond the areola to create a deep latch, which is essential for effective breastfeeding and to prevent nipple soreness.
Choice D rationale:
While babies do have natural instincts to breastfeed, it is essential to provide the mother with specific guidance on achieving a proper latch to ensure successful breastfeeding.


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Question 20:

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

Explanation

Choice A rationale:
Elevating the client's legs is not the first action to address late decelerations. Positioning the client on her side is the priority intervention.
Choice B rationale:
Administering oxygen via a face mask is an appropriate intervention for late decelerations, but it is not the first action. Positioning the client on her side is the priority.
Choice C rationale:
Positioning the client on her side can relieve pressure on the vena cava and improve fetal oxygenation, which is crucial in managing late decelerations.
Choice D rationale:
Increasing the infusion rate of the IV fluid may not directly address the cause of late decelerations and is not the first action to take in this situation.


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Question 21:

A nurse is reinforcing teaching with a client who is at 6 weeks of gestation. The client tells the nurse that she smokes one pack of cigarettes per day. The nurse should instruct the client that her newborn is at increased risk for which of the following clinical manifestations?

Explanation

Choice A rationale:
Craniofacial abnormalities are not directly associated with maternal smoking during pregnancy. However, smoking during pregnancy can have other adverse effects on the baby's development.
Choice B rationale:
Maternal smoking during pregnancy is a significant risk factor for delivering a baby with low birth weight. Smoking can lead to restricted blood flow to the placenta, affecting the baby's growth and development.
Choice C rationale:
Hypersensitivity to noise is not a common clinical manifestation associated with maternal smoking during pregnancy.
Choice D rationale:
Hyperactivity is not a common clinical manifestation associated with maternal smoking during pregnancy. However, smoking during pregnancy can have other effects on the child's behavior and development later in life.


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Question 22:

A nurse is reinforcing teaching with a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSAFP) determination. Which of the following information should the nurse include?

Explanation

Choice A rationale:
Maternal serum alpha-fetoprotein (MSAFP) determination is not used to screen for ABO incompatibility. It is specifically used to screen for certain fetal abnormalities.
Choice B rationale:
MSAFP determination is not used to screen for gestational diabetes. It is primarily used for detecting certain fetal abnormalities.
Choice C rationale:
The MSAFP test is a prenatal screening test that measures the level of alpha-fetoprotein in the mother's blood. Abnormal levels of alpha-fetoprotein may indicate a neural tube defect, such as spina bifida, or other chromosomal abnormalities.
Choice D rationale:
MSAFP determination is not used to screen for fetal maturity. It is used to assess the risk of certain fetal abnormalities.


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Question 23:

A nurse is reinforcing discharge teaching about circumcision care with the parent of a newborn who had a circumcision using the Plastibell device. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

Explanation

Choice A rationale:
This statement indicates an understanding that a loose-fitting diaper will help prevent irritation and promote healing after circumcision.
Choice B rationale:
Applying petroleum jelly to the circumcision site helps keep the area moist and prevents the Plastibell from sticking to the penis during healing.
Choice C rationale:
While keeping the penis clean is essential, the use of soap is usually not recommended for the first few days after circumcision. Warm water and gentle patting are generally sufficient.
Choice D rationale:
Bleeding after circumcision should be reported to the doctor as it may indicate a complication that needs attention.
Choice E rationale:
The Plastibell device typically falls off on its own within a week after the circumcision procedure.


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Question 24:

A nurse is teaching a new mother about the signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

Explanation

Choice A rationale:
A newborn can lose up to 10% of their birth weight in the first few days after birth, which is considered normal. By 7-14 days of age, the baby should have regained their birth weight if breastfeeding effectively.
Choice B rationale:
Gaining 0.25 oz (7 grams) per day after the fourth day of life is not a standard guideline for assessing effective breastfeeding.
Choice C rationale:
Expecting the baby to have less than 5 wet diapers per day after the fourth day of life may indicate dehydration or inadequate breastfeeding, which is not a sign of effective breastfeeding.
Choice D rationale:
Expecting the baby to feed constantly during the first week of life is not necessarily an indicator of effective breastfeeding. While frequent feeding is normal in the early days, the baby should be able to effectively feed and show signs of satiety after nursing.


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Question 25:

A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?

Explanation

Choice A rationale:
Broccoli is not a reliable source of Vitamin B12. It is a good source of other nutrients like Vitamin C and fiber.
Choice B rationale:
Skim milk is a reliable source of Vitamin B12 and is often fortified with this essential vitamin.
Choice C rationale:
Figs are not a reliable source of Vitamin B12. They are a good source of fiber and certain minerals, but they do not contain Vitamin B12.
Choice D rationale:
Stewed tomatoes are not a reliable source of Vitamin B12. They are a good source of certain vitamins and minerals, but not Vitamin B12.


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