ATI Maternal Newborn Proctored

Exam SUMMER 2022.

ATI Maternal Newborn Proctored Exam

SUMMER 2022.

1. Two days after delivery, a postpartum client preparesfor discharge. Whatshould the nurse teach

her about lochia flow?

A.Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia

serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.

B.Incorrect: Numerous clots are abnormal and should be reported to the physician.

C.Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum

hemorrhage.

D.Correct: Lochia normally lastsfor about 21 days, and changes from a bright red, topinkish

brown,to creamy white.

EXPLANATION;The color ofthe lochia changes from a bright red to white after four daysNumerous

large clots are normal for the next three to four days

Saturation of the perineal pad with blood is expected when getting up from the bed

Lochia should last for about 3 weeks, changing color every few days

2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the

contractions, the fetal heart rate hasrepeatedly dropped 30 beats/min below the baseline. Late

decelerations are suspected and the nurse notifies the physician. Which is the rationale for this

action?

A.Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late

decelerations.

B.Incorrect: Variable decelerations(not late decelerations) are associated with cord compression.

C.Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of

maternal contractions.

D.Correct: Late decelerations are associated with uteroplacental insufficiency and are a signof

fetalhypoxia. Repeated late decelerations indicate fetal distress.

EXPLANATION;The umbilical cord is wrapped tightly around the fetus' neck

The fetal cord is being compressed due to rapid descent of the fetal head

Maternal contractions are not adequate enough to deliver the fetus

The fetusis not receiving adequate oxygen and is in distress

3. Which preoperative nursing interventionsshould be included for a client who isscheduled to have

an emergency cesarean birth?

A.Incorrect: Monitoring O2 saturations and administering pain medications are postoperative

interventions.

B.Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the

client regarding breathing exercisesis not appropriate in a crisis situation when the client's anxiety is

high,because information would probably not be retained. In an emergency, there is time only for

essential interventions.

C.Correct: Because thisis an emergency,surgery must be performed quickly. Anxiety oftheclient and

the family will be high. Inserting an indwelling catheter helps to keep thebladder empty and free

from injury when the incision is made.