ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
A client at 36-weeks gestation is admitted to the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. The client's blood pressure is 150/100 mm Hg. What condition should the nurse suspect?
Correct Answer: B
Rationale: In this scenario, the nurse should suspect preeclampsia. Preeclampsia is characterized by high blood pressure (≥140/90 mm Hg) and proteinuria after 20 weeks of gestation in a previously normotensive woman. The presence of severe headache, visual disturbances, and epigastric pain further supports this diagnosis. If left untreated, preeclampsia can progress to eclampsia, which involves seizures. Gestational hypertension refers to elevated blood pressure without proteinuria after 20 weeks of gestation. Chronic hypertension predates pregnancy or occurs before 20 weeks of gestation. Educationally, understanding the nuances between these conditions is vital for nurses working in maternity care. Recognizing the signs and symptoms of preeclampsia is crucial for timely intervention to prevent severe complications for both the mother and the baby. Nurses must be able to differentiate between these hypertensive disorders to provide appropriate care and ensure optimal outcomes for pregnant individuals.
Question 2 of 5
A client at 38-weeks gestation is admitted to the labor and delivery unit with complaints of decreased fetal movement. The client's cervix is dilated 1 cm, 20% effaced, and the fetus is at -3 station. What action should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first in this scenario is to perform a nonstress test (Option A). A nonstress test is a non-invasive way to assess fetal well-being by evaluating the fetal heart rate in response to fetal movement. In this case, the client's complaint of decreased fetal movement coupled with the clinical findings of cervical dilation, effacement, and fetal station indicate a need for immediate assessment of fetal well-being. Administering oxygen via face mask (Option B) may be indicated if there are signs of fetal distress, but assessing fetal well-being through a nonstress test should be the priority in this situation. Notifying the healthcare provider (Option C) can be important, but immediate assessment of fetal well-being should precede this step. Performing a biophysical profile (Option D) may provide more comprehensive information about fetal well-being, but it is a more time-consuming test compared to a nonstress test and may not be feasible as the first step when there are concerns about decreased fetal movement. In an educational context, understanding the rationale behind prioritizing actions in obstetric emergencies is crucial for nurses working in labor and delivery units. Recognizing the significance of prompt assessment and intervention in cases of decreased fetal movement can help prevent adverse outcomes for both the fetus and the mother. It is important for nurses to be able to prioritize actions based on the client's condition and current evidence-based guidelines to provide safe and effective care.
Question 3 of 5
A 39-week gestational multigravida is admitted to labor and delivery spontaneous rupture of membranes and contraction occurring 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6cm, 90% effaced and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has ranged between 170 and 180 beats/minute. What action should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to implement is Option B: Take an oral maternal temperature. This is the most appropriate immediate action because the fetal heart rate is elevated, which could indicate maternal fever, a potential sign of infection. Monitoring the maternal temperature will provide crucial information for assessing the possibility of maternal infection, which could be affecting the fetus as well. Option A, obtaining a blood specimen for hemoglobin, is not the priority in this situation as it does not address the immediate concern of the elevated fetal heart rate. Option C, straight catheterizing the client, is not indicated based on the information provided. Option D, sending amniotic fluid for analysis, is not the most immediate action needed to address the current situation. Educationally, this scenario highlights the importance of recognizing abnormal fetal heart rate patterns and understanding their potential implications for both the mother and the baby. It emphasizes the need for timely and appropriate nursing interventions in labor and delivery settings to ensure the well-being of both the mother and the fetus.
Question 4 of 5
A client who is 3 weeks postpartum tells the nurse. 'I am so tired all the time. I didn't know having a baby would be so hard.' What response should the nurse provide.
Correct Answer: A
Rationale: The correct response to the client who is 3 weeks postpartum expressing fatigue is option A) "It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps." This response is appropriate because it acknowledges the client's feelings as normal and provides a practical suggestion to help manage fatigue. Option B) is incorrect because it minimizes the client's experience by suggesting that feeling tired is only expected for the first couple of weeks, which may invalidate the client's feelings and concerns. Option C) is not the best response as it focuses solely on housework and family support, rather than addressing the client's emotional and physical well-being. Option D) is not the optimal choice as it asks for more information without providing immediate validation or support to the client's feelings of exhaustion. In an educational context, it is essential for nurses to validate clients' experiences, provide empathetic responses, and offer practical strategies to manage common postpartum challenges. By understanding the physical and emotional demands of the postpartum period, nurses can better support clients in their transition to motherhood.
Question 5 of 5
One hour after delivery the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next.
Correct Answer: C
Rationale: In this scenario, the correct intervention for the nurse to implement next is option C: palpating the suprapubic area for bladder distention. This is the most appropriate action because a distended bladder can displace the uterus and prevent proper contraction, leading to postpartum hemorrhage. By assessing for bladder distention, the nurse can address this potential issue promptly. Option A is incorrect because documenting the number of pad changes does not address the immediate concern of a potentially distended bladder impacting uterine contraction. Option B is not the priority as assessing bladder distention takes precedence over ensuring the client can void. Option D is also incorrect as increasing the rate of oxytocin infusion without addressing the bladder distention could exacerbate the issue. Educationally, this scenario highlights the importance of prompt assessment and intervention in postpartum care. Nurses need to prioritize interventions based on potential complications that could arise post-delivery to ensure the well-being of the mother and prevent complications such as postpartum hemorrhage. Understanding the physiological changes that occur in the immediate postpartum period is crucial for providing effective and timely care to maternity patients.