ATI-MN ATI Maternal Newborn Exam - Set 3 - Part 2

Correct Answer: Keep the client lying down a while

After a prostaglandin is placed, the client stays lying down for a time so the medication stays in place and the nurse can monitor contractions and the fetal heart rate. Option b is incorrect because oxytocin is delayed for several hours after a prostaglandin to avoid excessive contractions. Option c is incorrect because the client requires monitoring after the medication, not discharge home. Option d is incorrect because walking right away can dislodge the medication and limits early monitoring.

Correct Answer: Bulging of the perineum

Bulging of the perineum and crowning of the head indicate the fetus is descending and birth is near during the second stage of labor. Option a is incorrect because the placenta is expelled in the third stage, after the newborn is born. Option b is incorrect because the latent phase is the early part of the first stage, not a sign that birth is near. Option d is incorrect because dilation of three centimeters occurs in the first stage, well before birth.

Correct Answer: A sudden gush of dark blood

A sudden gush of dark blood, along with cord lengthening and a firmly contracting fundus, signals that the placenta is separating during the third stage. Option b is incorrect because separation involves a gush of blood, not a complete stop in bleeding. Option c is incorrect because the cord lengthens rather than shortens as the placenta detaches. Option d is incorrect because the fundus becomes firm and globular with separation, not soft and boggy.

Correct Answer: Scalp swelling that resolves in days

Vacuum-assisted birth often causes scalp swelling called caput succedaneum, which crosses the suture lines and usually resolves within a few days. Option a is incorrect because newborn reflexes should be present; their absence would be an abnormal finding to report. Option b is incorrect because facial nerve paralysis is associated with forceps pressure, not the vacuum. Option c is incorrect because the swelling is temporary, not a permanent skull deformity.

Correct Answer: Insert an indwelling urinary catheter

An indwelling urinary catheter is inserted before a cesarean to keep the bladder empty, which lowers the risk of injury during the surgery. Option a is incorrect because the client is kept without food before surgery to reduce the risk of aspiration. Option c is incorrect because a wedge is placed under one hip to prevent vessel compression, so the client is not positioned flat. Option d is incorrect because informed consent is obtained before surgery, not withheld.

Correct Answer: Endometritis

A tender uterus with foul-smelling lochia points to endometritis, an infection of the uterine lining that requires prompt assessment and antibiotic treatment. Option a is incorrect because normal involution produces lochia without a foul odor and without uterine tenderness. Option b is incorrect because deep-vein thrombosis causes leg pain and swelling, not uterine tenderness and odor. Option d is incorrect because bladder distention displaces the fundus but does not cause foul-smelling lochia.

Correct Answer: Signs of uterine rupture

A client laboring after a previous cesarean is at risk for uterine rupture, so the nurse watches for sudden pain, loss of contractions, and a nonreassuring fetal heart rate. Option b is incorrect because bloody show is an expected sign of cervical change during labor. Option c is incorrect because a reactive fetal heart rate is reassuring and not a complication. Option d is incorrect because mild practice contractions are a normal finding rather than a serious complication.

Correct Answer: Lift the presenting part off the cord

With a prolapsed cord, the nurse uses a gloved hand to lift the presenting part off the cord, relieving compression and protecting fetal blood flow until birth. Option a is incorrect because a knee-chest or Trendelenburg position, not high Fowler, helps relieve cord pressure. Option b is incorrect because pushing the cord back can damage it and worsen compression. Option d is incorrect because the nurse must stay and relieve the pressure while calling for help, not leave the client.

Correct Answer: Knee-chest position

The knee-chest position uses gravity to shift the fetus off the cord, relieving compression and helping maintain blood flow to the fetus until birth. Option a is incorrect because standing is unsafe and does not relieve pressure on the cord. Option b is incorrect because lying flat does not relieve cord compression the way the knee-chest position does. Option c is incorrect because high Fowler does not move the fetus off the cord and can increase pressure.

Correct Answer: Uterine rupture

A tearing sensation with sharp pain, loss of contractions, and a falling fetal heart rate suggests uterine rupture, an emergency that requires immediate cesarean birth. Option a is incorrect because bladder distention displaces the fundus but does not cause a tearing sensation and fetal heart rate drop. Option c is incorrect because false labor produces irregular contractions, not the emergency findings described here. Option d is incorrect because transition involves strong contractions and the urge to push, not their sudden loss with tearing pain.

Correct Answer: Amniotic fluid embolism

Sudden chest pain, shortness of breath, and circulatory collapse around the time of birth suggest an amniotic fluid embolism, a life-threatening emergency needing immediate support. Option a is incorrect because diastasis recti is a separation of abdominal muscles and is unrelated to these emergency findings. Option b is incorrect because mastitis is a breast infection that develops later, not acute cardiopulmonary collapse. Option c is incorrect because postpartum blues involves mood changes, not sudden respiratory and circulatory collapse.

Correct Answer: Stay with the client and support delivery

During a precipitous birth, the nurse stays with the client and supports a controlled delivery, applying gentle pressure to prevent rapid expulsion and injury. Option a is incorrect because crossing the legs to delay birth is unsafe and can injure the client and fetus. Option c is incorrect because the nurse must not leave the client during an imminent birth; help is called for instead. Option d is incorrect because holding the head back can harm the fetus; the nurse uses only gentle control.

Correct Answer: At one and five minutes after birth

Apgar scoring is performed at one and five minutes after birth to assess the newborn's transition to life outside the uterus and the need for support. Option a is incorrect because the Apgar score is not an hourly assessment throughout the first day. Option b is incorrect because a single score does not capture how the newborn adapts over the first minutes. Option d is incorrect because the standard times are one and five minutes, not thirty and sixty minutes.

Correct Answer: Fundal firmness and lochia

The fourth stage carries the greatest risk of hemorrhage, so the nurse prioritizes assessing fundal firmness and lochia to detect bleeding early. Option b is incorrect because birth preferences guide labor planning but are not the priority assessment after birth. Option c is incorrect because discharge planning is appropriate later, not during the critical first hours after birth. Option d is incorrect because a feeding schedule, while useful, is not the priority during the immediate recovery period.

Correct Answer: Massage the fundus

A boggy fundus indicates the uterus is not contracting well, so the nurse massages it first to stimulate contraction and reduce the risk of hemorrhage. Option a is incorrect because the nurse can correct a boggy fundus at the bedside with massage before notifying the provider. Option c is incorrect because room temperature does not affect uterine tone or bleeding. Option d is incorrect because ambulation is encouraged later and does not address the immediate atony.

Correct Answer: Progressive cervical dilation

The goal of augmentation is effective labor, so progressive cervical dilation with a regular contraction pattern shows the oxytocin is working as intended. Option a is incorrect because absent fetal heart tones is an emergency, not a desired effect. Option b is incorrect because a uterus that never relaxes signals overstimulation and endangers the fetus. Option d is incorrect because contractions every minute are too frequent and reduce fetal oxygen delivery.

Correct Answer: Below the umbilicus

With a vertex presentation, the fetal back lies low, so the fetal heart tones are heard most clearly below the client's umbilicus. Option b is incorrect because the upper chest is not where fetal heart tones are auscultated. Option c is incorrect because the shoulder area is not a location for hearing the fetal heart tones. Option d is incorrect because heart tones above the umbilicus suggest a breech presentation, not vertex.

Correct Answer: It is a reassuring finding

Moderate variability of the fetal heart rate baseline is reassuring, reflecting a well-oxygenated fetus with an intact nervous system, so no intervention is required. Option a is incorrect because cord prolapse produces sudden decelerations, not reassuring moderate variability. Option b is incorrect because absent or minimal variability, not moderate variability, raises concern for hypoxia. Option c is incorrect because a reassuring pattern supports continuing labor rather than stopping it.

Correct Answer: They redirect focus and aid relaxation

Patterned breathing redirects the client's focus and promotes relaxation, which reduces the tension and anxiety that can heighten the perception of labor pain. Option b is incorrect because breathing techniques ease coping with contractions but do not stop them. Option c is incorrect because fetal and maternal monitoring continues regardless of comfort techniques. Option d is incorrect because breathing techniques aid comfort but do not directly speed cervical dilation.

Correct Answer: It does not require ruptured membranes

External monitoring is noninvasive and does not require ruptured membranes or cervical dilation, so the nurse can apply it without those conditions. Option a is incorrect because external monitoring shows contraction timing but cannot measure exact contraction strength. Option b is incorrect because the nurse can apply external monitors, which do not require a provider to place. Option d is incorrect because external monitoring does not require a dilated cervix, unlike internal monitoring.