ATI-MN ATI Maternal Newborn Exam - Set 3 - Part 1

Correct Answer: Cervical dilation

Cervical dilation is the single best indicator of labor progress, since labor advances as the cervix opens from closed toward full dilation to allow birth. Option b is incorrect because comfort level varies widely between clients and does not reliably show cervical change. Option c is incorrect because the maternal heart rate reflects overall status but does not measure how far labor has advanced. Option d is incorrect because bloody show signals cervical activity but does not measure the actual dilation that marks progress.

Correct Answer: Progressive cervical dilation

True labor produces progressive cervical dilation and effacement, which is the defining difference that separates it from the irregular contractions of false labor. Option a is incorrect because contractions that ease with walking point to false labor, whereas true labor continues despite activity. Option b is incorrect because contractions that stop with rest suggest false labor; true labor contractions persist. Option d is incorrect because true labor pain often starts in the back and radiates forward, not in the abdomen alone.

Correct Answer: Assess the fetal heart rate

After membranes rupture, the nurse first assesses the fetal heart rate to detect a prolapsed cord, which can compress and cut off the fetal oxygen supply. Option a is incorrect because changing the gown is a comfort task that does not address the immediate risk to the fetus. Option b is incorrect because documenting the time matters but comes after confirming the fetus is not in distress. Option c is incorrect because offering fluids is a routine measure and is not the priority right after rupture.

Correct Answer: Late decelerations

A heart rate that dips after the contraction peak and returns slowly is a late deceleration, which suggests the placenta is not delivering enough oxygen to the fetus. Option b is incorrect because variable decelerations are abrupt and vary in timing, unlike this consistent dip after the peak. Option c is incorrect because accelerations are brief increases in the heart rate, not the decreases described here. Option d is incorrect because early decelerations mirror the contraction and are caused by head compression, a benign finding.

Correct Answer: Stop the oxytocin infusion

Late decelerations signal reduced placental blood flow, so the nurse first stops the oxytocin to lessen contractions and improve oxygen delivery to the fetus. Option a is incorrect because increasing the rate intensifies contractions and further reduces fetal oxygen. Option b is incorrect because late decelerations require immediate intervention, not delayed rechecking. Option d is incorrect because side-lying, not upright positioning, improves placental flow, and the priority is stopping the oxytocin.

Correct Answer: Reposition the client

Variable decelerations usually come from cord compression, so repositioning the client first often relieves pressure on the cord and improves the fetal heart rate. Option b is incorrect because forceps are not the first response; relieving cord pressure with position change comes first. Option c is incorrect because increasing oxytocin strengthens contractions and can worsen cord compression. Option d is incorrect because lying flat can lower blood pressure and does not relieve the cord compression causing the pattern.

Correct Answer: It is a reassuring sign

Accelerations of the fetal heart rate with movement are reassuring, reflecting an intact nervous system and adequate oxygenation, so no intervention is needed. Option a is incorrect because cord compression produces variable decelerations, not the accelerations described here. Option b is incorrect because a reassuring pattern does not call for oxygen by mask. Option c is incorrect because accelerations indicate well-being rather than distress.

Correct Answer: Cervical dilation of four to seven centimeters

During the active phase of the first stage, the cervix dilates from about four to seven centimeters as contractions become stronger and more regular. Option a is incorrect because delivery of the placenta occurs in the third stage, well after the active phase. Option b is incorrect because full dilation with the urge to push marks the transition into the second stage, not the active phase. Option d is incorrect because a closed cervix occurs before labor begins, not during active labor.

Correct Answer: Offer encouragement and support

Transition is the most intense and discouraging phase, so offering steady encouragement and support helps the client cope while the nurse confirms readiness before pushing. Option b is incorrect because transition is usually short, and telling the client it lasts hours would add to her distress. Option c is incorrect because the client needs presence and support during this difficult phase, not to be left alone. Option d is incorrect because pushing before full dilation can injure the cervix, so the nurse confirms dilation first.

Correct Answer: Give an intravenous fluid bolus

An epidural can cause maternal low blood pressure, so an intravenous fluid bolus beforehand helps expand circulating volume and prevent a sudden drop. Option a is incorrect because the client cannot safely walk after an epidural, and standing does not prevent the blood pressure drop. Option b is incorrect because restricting fluids would increase, not decrease, the risk of low blood pressure. Option c is incorrect because lying flat can worsen low blood pressure by letting the uterus compress a major vessel.

Correct Answer: Turn the client to her side

Turning the client to her side relieves pressure on the major vessel and improves blood return, which helps correct the low blood pressure after an epidural. Option a is incorrect because the client needs prompt assessment and intervention, not withholding of care. Option b is incorrect because fluids are increased, not slowed, to support blood pressure after an epidural. Option d is incorrect because sitting upright does not relieve the vessel compression contributing to the low blood pressure.

Correct Answer: Naloxone

Opioids given near delivery can depress the newborn's breathing, so the nurse keeps naloxone available to reverse opioid-induced respiratory depression in the newborn. Option a is incorrect because oxytocin stimulates uterine contractions and does not reverse newborn respiratory depression. Option c is incorrect because betamethasone promotes fetal lung maturity and is not an opioid antidote. Option d is incorrect because magnesium sulfate is used for seizure prevention and tocolysis, not opioid reversal.

Correct Answer: That labor is well established

The nurse confirms labor is well established before giving an opioid, because medicating too early can slow the progress of labor. Option a is incorrect because a closed cervix means labor has not progressed, which is not when an opioid is appropriate. Option b is incorrect because recent eating is not the deciding factor for opioid administration in labor. Option c is incorrect because giving an opioid right before birth risks depressing the newborn's breathing.

Correct Answer: A spinal fluid leak

A headache that worsens when upright after spinal anesthesia suggests leaking spinal fluid, and a blood patch is the most reliable treatment for relief. Option b is incorrect because ordinary fatigue does not produce a headache that clearly worsens when the client sits up. Option c is incorrect because preeclampsia headaches are not positional and come with high blood pressure, unlike a spinal fluid leak. Option d is incorrect because an allergic reaction causes itching, rash, or swelling rather than a position-related headache.

Correct Answer: Apply sacral counterpressure

Firm sacral counterpressure with the heel of the hand helps relieve the lower back pain many clients feel during labor, especially with an occiput-posterior position. Option a is incorrect because the supine position can worsen back pain and lower blood pressure, so it is not used for comfort. Option b is incorrect because therapeutic touch and massage often ease labor pain rather than being withheld. Option c is incorrect because rapid shallow breathing can cause lightheadedness and tingling rather than relieving pain.

Correct Answer: Have her breathe into cupped hands

Breathing into cupped hands lets the client rebreathe carbon dioxide, which corrects the imbalance from hyperventilation and relieves the tingling and lightheadedness. Option b is incorrect because faster breathing would blow off more carbon dioxide and worsen the symptoms. Option c is incorrect because high-flow oxygen does not correct the carbon dioxide loss causing the tingling. Option d is incorrect because the problem is a breathing imbalance, which positioning and leg elevation do not fix.

Correct Answer: Contractions every minute without rest

Contractions that come every minute without time to relax reduce placental blood flow, so the nurse intervenes by stopping the oxytocin to protect the fetus. Option a is incorrect because a uterus that relaxes between contractions is the desired resting tone, not a problem. Option c is incorrect because moderate contractions lasting about a minute reflect an expected, effective pattern. Option d is incorrect because contractions every three minutes fall within an acceptable pattern during induction.

Correct Answer: Reduced fetal oxygenation

The fetus receives the most oxygen when the uterus relaxes between contractions, so a uterus that does not relax raises the risk of reduced fetal oxygenation. Option a is incorrect because excessive uterine activity can lead to complications rather than lowering bleeding risk. Option b is incorrect because constant uterine tone does not speed healing and instead endangers the fetus. Option d is incorrect because the lack of relaxation decreases, rather than improves, fetal oxygen delivery.

Correct Answer: That the presenting part is engaged

The presenting part should be engaged before an amniotomy, because a high presenting part allows the cord to slip down and prolapse when fluid escapes. Option a is incorrect because recent eating is not the safety concern that guides timing of an amniotomy. Option b is incorrect because the procedure is performed during labor with cervical change, not when the cervix is fully closed. Option c is incorrect because the client is positioned lying down for the procedure, not standing.

Correct Answer: Green-tinged amniotic fluid

Green-tinged fluid indicates meconium, which can signal fetal stress, so the nurse reports it and prepares for possible newborn resuscitation at birth. Option a is incorrect because a fetal heart rate of 140 is within the normal range and is reassuring. Option c is incorrect because contractions commonly increase after an amniotomy, which is an expected effect. Option d is incorrect because clear, watery fluid is the expected normal finding after rupture of membranes.