ATI Remediations 2/8/2021
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following
actions should the nurse plan to take?
- Correct: Stand at the clients right side if the nurse is right-handed.
o Rationale: The nurse should stand facing the client on the side that correlates with the
nurse’s dominant hand; therefore, if the nurse is right-handed, the nurse should stand at
the client’s right side.
- Incorrect: Ensure the client has a full bladder.
o Rationale: The nurse should assist the client to empty her bladder.
- Incorrect: Assist the client onto her back with knees extended.
o Rationale: Placing the client in a supine position increases the risk of supine
hypotension.
- Incorrect: Palpate the outline of the fetus’s head with the palms of the hands.
o Rationale: The nurse should palpate the fetus’s head with the fingertips.
A nurse is reviewing the provider’s admission orders for a client who is at 37 weeks of gestation and is
HIV positive. Which of the following orders should the nurse clarify with the provider?
- Correct: Fetal scalp electrode
o Rationale: The placement scalp electrode is an invasive procedure that requires
ruptured membranes.
- Incorrect: Intermittent auscultation
o Rationale: Intermittent auscultation with a Doppler is a noninvasive and safe method of
fetal monitoring for a patient who is HIV positive.
- Incorrect: Biophysical profile
o Rationale: A biophysical profile includes an ultrasound and external fetal monitoring. It
is noninvasive.
- Incorrect: Non-stress test (NST)
o Rationale: A NST includes the application of external fetal and uterine monitors. It is
noninvasive.
A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the
following findings should the nurse identify as a presumptive indication of pregnancy?
- Correct: Report of fetal movement by the client
o Rationale: Quickening begins around 18 to 20 weeks of gestation and is considered a
resumptive indication of pregnancy.
- Incorrect: Auscultation of the fetal heart rate with Doppler ultrasound
o Rationale: The fetal heart rate can be auscultated with Doppler ultrasound around 10 to
12 weeks gestation and is considered a positive indication of pregnancy.
- Incorrect: Presence of Chadwick’s sign on pelvic examination
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, o Rationale: Chadwick’s sign is visible around 6 weeks of gestation and is considered a
probable indication of pregnancy.
- Incorrect: Report of Braxton-Hicks contractions by the client
o Rationale: Braxton-Hicks contractions might be reported by the client as early as 20
weeks of gestation and are considered a probable indication of pregnancy.
A nurse is planning care for a client who is postpartum and has cardiac disease. For which o the
following prescriptions should the nurse seek clarification?
- Correct: Monitor the client’s weight weekly
o Rationale: The nurse should weigh the client daily to monitor for fluid overload.
- Incorrect: Monitor the client’s intake and output
o Rationale: The nurse should monitor the client’s intake and output because blood flow
to and from the heart increases for at least the first 24 hrs after delivery.
- Incorrect: Initiate a high-fiber diet for the client
o Rationale: A client who has cardiac disease should follow a high-fiber diet to prevent
straining with bowel movements because the pushing effort can result in cardiac stress.
- Incorrect: Initiate bedrest with the head of the bed elevated
o Rationale: The nurse should initiate bedrest with the head of the bed elevated to
promote rest and decrease the client’s oxygen consumption.
A nurse is caring for a client who is in the first stage of labor. Which of the following findings should
the nurse identify as a cause for concern?
- Correct: Contractions lasting 100 seconds
o Rationale: Contractions during the first stage of labor range from 45 to 80 seconds. They
should not exceed 90 seconds.
- Incorrect: Pink, mucoid vaginal discharge
o Rationale: This is an expected finding during labor
- Incorrect: Brownish vaginal discharge
o Rationale: This could be the result of cervical trauma from vaginal examinations or
recent vaginal intercourse.
- Incorrect: Contractions occurring every 4 to 5 minutes
o Rationale: Contraction frequency ranges from 2 to 5 contractions per 10 minutes during
labor.
A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the
presence of meconium-stained fluid. Which of the following actions should the nurse take?
- Correct: Gather equipment for neonatal resuscitation
o Rationale: Meconium-stained amniotic fluid can cause neonatal meconium aspiration
syndrome.
This study source was downloaded by 100000829216747 from CourseHero.com on 02-11-2022 04:57:41 GMT -06:00
https://www.coursehero.com/file/86516227/ATI-Remediations-2-8-2021docx/
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following
actions should the nurse plan to take?
- Correct: Stand at the clients right side if the nurse is right-handed.
o Rationale: The nurse should stand facing the client on the side that correlates with the
nurse’s dominant hand; therefore, if the nurse is right-handed, the nurse should stand at
the client’s right side.
- Incorrect: Ensure the client has a full bladder.
o Rationale: The nurse should assist the client to empty her bladder.
- Incorrect: Assist the client onto her back with knees extended.
o Rationale: Placing the client in a supine position increases the risk of supine
hypotension.
- Incorrect: Palpate the outline of the fetus’s head with the palms of the hands.
o Rationale: The nurse should palpate the fetus’s head with the fingertips.
A nurse is reviewing the provider’s admission orders for a client who is at 37 weeks of gestation and is
HIV positive. Which of the following orders should the nurse clarify with the provider?
- Correct: Fetal scalp electrode
o Rationale: The placement scalp electrode is an invasive procedure that requires
ruptured membranes.
- Incorrect: Intermittent auscultation
o Rationale: Intermittent auscultation with a Doppler is a noninvasive and safe method of
fetal monitoring for a patient who is HIV positive.
- Incorrect: Biophysical profile
o Rationale: A biophysical profile includes an ultrasound and external fetal monitoring. It
is noninvasive.
- Incorrect: Non-stress test (NST)
o Rationale: A NST includes the application of external fetal and uterine monitors. It is
noninvasive.
A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the
following findings should the nurse identify as a presumptive indication of pregnancy?
- Correct: Report of fetal movement by the client
o Rationale: Quickening begins around 18 to 20 weeks of gestation and is considered a
resumptive indication of pregnancy.
- Incorrect: Auscultation of the fetal heart rate with Doppler ultrasound
o Rationale: The fetal heart rate can be auscultated with Doppler ultrasound around 10 to
12 weeks gestation and is considered a positive indication of pregnancy.
- Incorrect: Presence of Chadwick’s sign on pelvic examination
This study source was downloaded by 100000829216747 from CourseHero.com on 02-11-2022 04:57:41 GMT -06:00
https://www.coursehero.com/file/86516227/ATI-Remediations-2-8-2021docx/
, o Rationale: Chadwick’s sign is visible around 6 weeks of gestation and is considered a
probable indication of pregnancy.
- Incorrect: Report of Braxton-Hicks contractions by the client
o Rationale: Braxton-Hicks contractions might be reported by the client as early as 20
weeks of gestation and are considered a probable indication of pregnancy.
A nurse is planning care for a client who is postpartum and has cardiac disease. For which o the
following prescriptions should the nurse seek clarification?
- Correct: Monitor the client’s weight weekly
o Rationale: The nurse should weigh the client daily to monitor for fluid overload.
- Incorrect: Monitor the client’s intake and output
o Rationale: The nurse should monitor the client’s intake and output because blood flow
to and from the heart increases for at least the first 24 hrs after delivery.
- Incorrect: Initiate a high-fiber diet for the client
o Rationale: A client who has cardiac disease should follow a high-fiber diet to prevent
straining with bowel movements because the pushing effort can result in cardiac stress.
- Incorrect: Initiate bedrest with the head of the bed elevated
o Rationale: The nurse should initiate bedrest with the head of the bed elevated to
promote rest and decrease the client’s oxygen consumption.
A nurse is caring for a client who is in the first stage of labor. Which of the following findings should
the nurse identify as a cause for concern?
- Correct: Contractions lasting 100 seconds
o Rationale: Contractions during the first stage of labor range from 45 to 80 seconds. They
should not exceed 90 seconds.
- Incorrect: Pink, mucoid vaginal discharge
o Rationale: This is an expected finding during labor
- Incorrect: Brownish vaginal discharge
o Rationale: This could be the result of cervical trauma from vaginal examinations or
recent vaginal intercourse.
- Incorrect: Contractions occurring every 4 to 5 minutes
o Rationale: Contraction frequency ranges from 2 to 5 contractions per 10 minutes during
labor.
A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the
presence of meconium-stained fluid. Which of the following actions should the nurse take?
- Correct: Gather equipment for neonatal resuscitation
o Rationale: Meconium-stained amniotic fluid can cause neonatal meconium aspiration
syndrome.
This study source was downloaded by 100000829216747 from CourseHero.com on 02-11-2022 04:57:41 GMT -06:00
https://www.coursehero.com/file/86516227/ATI-Remediations-2-8-2021docx/
