ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
A 38-week primigravida client who is positive for group A beta streptococcus receives a prescription for cefazolin 2 grams IV to be infused over 30 minutes. The medication is available in 2 grams/100 ml of normal saline. The nurse should program the infusion pump to deliver how many ml/hour?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) 200 ml/hr. The rationale behind this is that the nurse needs to administer cefazolin 2 grams IV over 30 minutes. The medication is available in a concentration of 2 grams/100 ml. Therefore, to deliver 2 grams of cefazolin, the nurse needs to infuse 100 ml of the medication. Since the infusion is to be completed over 30 minutes, which is half an hour, the nurse should calculate the infusion rate in ml/hour. Option A) 100 ml/hr is incorrect because this rate would deliver only half of the required dose in the specified time frame. Option C) 6 ml/hr and Option D) 1.6 ml/hr are also incorrect as they do not provide the necessary infusion rate to deliver the full 2 grams of cefazolin over 30 minutes. Educationally, this question assesses the nurse's understanding of medication administration and infusion rate calculations, which are crucial skills in providing safe and effective care to maternity patients. Nurses must be competent in calculating correct infusion rates to ensure that patients receive the prescribed medication in the appropriate dosage and time frame. Mastery of these calculations is essential for patient safety and quality care delivery in maternity settings.
Question 2 of 5
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) The client reports feeling a flushing sensation. - **Explanation of Correct Answer (D):** A flushing sensation is a common side effect of magnesium sulfate therapy. It indicates that the drug level has reached a therapeutic range for treating PIH. This symptom suggests vasodilation, which helps in controlling hypertension in the client. - **Explanation of Incorrect Answers:** - A) The client being oriented to date, time, and place is unrelated to the therapeutic level of magnesium sulfate. - B) Respiratory rate of 14 breaths per minute is within normal limits and does not directly indicate the achievement of therapeutic drug level. - C) Urinary output of 30 ml per hour is a concerning finding in a pregnant client and may indicate inadequate kidney perfusion, but it does not specifically indicate the therapeutic level of magnesium sulfate. - **Educational Context:** Understanding the assessment findings related to medication therapy is crucial for nurses caring for pregnant clients with complications like PIH. Recognizing the signs of therapeutic drug levels helps in providing safe and effective care to improve maternal and fetal outcomes. Educating nursing students on these assessment skills prepares them to deliver quality care in obstetric settings.
Question 3 of 5
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) A sterile glove and an amniotic hook. When a nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy, these tools are essential for the procedure. A sterile glove is necessary to maintain asepsis during the amniotomy, reducing the risk of infection to both the mother and the baby. An amniotic hook is used to artificially rupture the amniotic sac if it hasn't ruptured naturally, which can help progress labor. The other options are incorrect because they do not align with the specific procedure of an amniotomy. B) An electronic fetal monitor and a blood pressure cuff are used for monitoring fetal heart rate and maternal vital signs but are not directly related to performing an amniotomy. C) A blood pressure cuff and a doppler device are also used for monitoring maternal vital signs and fetal heart rate but are not required for an amniotomy. D) A speculum and a nitrazine pH test strip are used to assess for rupture of membranes but are not the tools needed for performing an amniotomy. In an educational context, understanding the correct equipment for procedures like an amniotomy is crucial for nurses providing care during labor and delivery. It ensures the safety and well-being of both the mother and the baby and demonstrates proper knowledge and skills in maternity care.
Question 4 of 5
The nurse is caring for a client at 39-weeks gestation who is admitted to the maternity unit in active labor. A vaginal exam reveals that her cervix is dilated 3 cm, 80% effaced, and the fetus is at -1 station. Based on these findings, which intervention should the nurse implement first?
Correct Answer: A
Rationale: In this scenario, the correct intervention is to encourage the client to use relaxation techniques (Option A) first. At 3 cm dilation, 80% effacement, and -1 station, the client is in active labor but not yet in advanced labor. Relaxation techniques can help the client cope with labor pain, reduce anxiety, and facilitate labor progression by promoting uterine blood flow and decreasing catecholamine levels that can inhibit contractions. Option B, assisting the client to ambulate in the hall, may be beneficial later in labor to promote fetal descent but is not the priority at this stage. Option C, applying an internal fetal scalp electrode, is an invasive procedure that is not indicated at this point unless there are specific fetal monitoring concerns. Option D, offering the client a warm shower, may provide comfort but is not as directly beneficial for labor progression as relaxation techniques. Educationally, understanding the rationale behind prioritizing relaxation techniques in early active labor helps nurses provide holistic and evidence-based care to laboring clients. It emphasizes the importance of non-pharmacological pain management strategies and individualized care based on the client's stage of labor.
Question 5 of 5
The nurse is caring for a client in active labor whose cervix is dilated 6 cm. The membranes rupture spontaneously, and the fetal monitor shows variable decelerations in the fetal heart rate. What action should the nurse take first?
Correct Answer: C
Rationale: In this scenario, the nurse's first action should be to change the maternal position (Option C). This is because variable decelerations in the fetal heart rate can indicate umbilical cord compression, and changing the maternal position can help relieve this compression by altering the baby's position in the uterus. This action is crucial in optimizing fetal oxygenation and reducing the risk of fetal distress. Assessing the amniotic fluid for meconium (Option A) may be important but is not the priority in this situation where fetal well-being is at risk. Performing a vaginal examination to assess for cord prolapse (Option B) could potentially worsen the cord compression if present, making it a dangerous choice as the first action. Lastly, preparing for an emergency cesarean section (Option D) is premature without exhausting less invasive interventions first. Educationally, this scenario highlights the importance of rapid and appropriate interventions in managing fetal distress during labor. It underscores the significance of understanding fetal monitoring patterns, knowing appropriate interventions, and prioritizing actions based on the situation's urgency to optimize maternal and fetal outcomes.