ATI RN
Needs of Maternal and Reproductive Health Clients Questions
Question 1 of 5
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings what actions the nurse implement.
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is option A) Notify the healthcare provider of the finding. This is the most appropriate response because a fundal height measurement that exceeds expected gestational age could indicate issues such as polyhydramnios, macrosomia, or incorrect gestational age assessment. Notifying the healthcare provider promptly allows for further assessment, monitoring, and potential intervention to ensure the well-being of both the mother and the twins. Option B) Documenting the finding in the medical record is important but not sufficient as the next course of action. While documentation is essential for continuity of care, the priority in this situation is to address the potential concerns raised by the fundal height measurement. Option C) Scheduling the client for a biophysical profile may be premature at this point as it is typically done to assess fetal well-being in high-risk pregnancies. Further assessment and guidance from the healthcare provider are needed before proceeding to this step. Option D) Requesting another nurse to measure the fundus is unnecessary as the issue lies not in the accuracy of the measurement but in the clinical significance of the measurement exceeding the expected value. Educationally, this question highlights the importance of recognizing abnormal findings in maternal health assessments and the significance of timely communication with the healthcare team to ensure appropriate management and care for the pregnant client and her twins. It reinforces the critical role of the nurse in advocating for the health and well-being of their clients by promptly reporting and acting on abnormal findings.
Question 2 of 5
The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: In this scenario, the correct intervention is to position the radiant warmer over the crib (Option A) first. This is crucial because the preterm infant is displaying signs of respiratory distress and decreased muscle tone, indicating a need for immediate thermal support to prevent further complications. Placing the infant under the radiant warmer will help maintain the infant's body temperature, which is vital for stabilizing their condition and preventing hypothermia. Assessing the infant's blood glucose level (Option B) is important but not the priority in this situation where respiratory distress and hypothermia are primary concerns. Nipple feeding 1 ounce 1% glucose in water (Option C) can wait until the infant's condition is stabilized. Placing the infant in a side-lying position (Option D) is not the most appropriate intervention given the presented symptoms. In an educational context, understanding the priority of interventions in neonatal care is crucial for nurses working in maternal and reproductive health. This scenario highlights the importance of prioritizing interventions based on the infant's immediate needs to ensure optimal outcomes in neonatal care.
Question 3 of 5
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Contraction duration of 100 seconds. Prolonged contractions can lead to uteroplacental insufficiency, reducing fetal oxygenation. If contractions last too long, there is not enough time for the placenta to replenish oxygen to the baby. This can result in fetal distress and compromise the well-being of the baby. Option A) Uterus soft would not be a reason to discontinue oxytocin as this is a normal finding during the initial stages of labor. Option C) Four contractions in 10 minutes could indicate tachysystole, which is a concern, but it is not as immediately dangerous as prolonged contractions. Option D) Early deceleration of fetal heart rate is concerning but may not necessarily warrant immediate discontinuation of oxytocin unless it persists or worsens. Educationally, this question highlights the importance of monitoring both maternal and fetal well-being during labor induction or augmentation. Understanding the implications of prolonged contractions on fetal oxygenation is crucial for safe maternal and neonatal outcomes.
Question 4 of 5
A diabetic client delivers a full-term large for gestation-age (LGA) infant who is jittery. What action should the nurse take first?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take first is to obtain a blood glucose level (Option C). This is crucial because the jitteriness in the LGA infant could be due to hypoglycemia, which is common in infants of diabetic mothers. By obtaining a blood glucose level, the nurse can quickly assess if the infant's symptoms are related to low blood sugar and take appropriate action to address it promptly. Administering oxygen (Option A) may not address the underlying cause of the jitteriness and could delay necessary interventions. Feeding the infant glucose water (Option B) without knowing the actual blood glucose level could potentially worsen the situation if the infant's blood sugar is already high. Decreasing environmental stimuli (Option D) is not the priority in this situation where a medical intervention is required. Educationally, understanding the relationship between maternal diabetes, LGA infants, and potential hypoglycemia is essential for nurses caring for maternal and reproductive health clients. It highlights the importance of timely assessments and interventions to ensure the well-being of both the mother and infant.
Question 5 of 5
A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement?
Correct Answer: D
Rationale: In this scenario, the correct action for the nurse to implement is option D, which is to have the client transported to the hospital. Placenta previa is a serious condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding for both the mother and the baby. Immediate medical intervention is necessary to ensure the safety of the woman and her unborn child. Option A is incorrect because scheduling weekly prenatal appointments would not address the urgent need for immediate medical attention in the case of placenta previa. Option B, while addressing the woman's homelessness, is not the most critical action to take at this moment. Option C, obtaining a hemoglobin and hematocrit level, is important in general prenatal care but is not the priority when managing a case of placenta previa with active bleeding. From an educational perspective, this scenario highlights the importance of recognizing and responding to obstetric emergencies promptly. Nurses working with maternal and reproductive health clients need to be well-versed in identifying high-risk conditions like placenta previa and understanding the appropriate actions to take to ensure the safety and well-being of both the pregnant woman and her baby. Early recognition and intervention can significantly impact the outcomes in such critical situations.