ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?
Correct Answer: C
Rationale: In the case of a client admitted with total placenta previa, the most critical finding for the nurse to report to the healthcare provider immediately is the onset of uterine contractions (Option C). This is because in placenta previa, where the placenta partially or completely covers the cervix, uterine contractions can lead to severe bleeding due to the detachment of the placenta from the uterine wall. This situation can rapidly escalate into a life-threatening emergency for both the mother and the fetus. Option A, a heart rate of 100 beats/minute, though abnormal, may not be as urgent in this scenario as the risk of hemorrhage from uterine contractions. Option B, variable fetal heart rate, while concerning, is not as immediate a concern as uterine contractions leading to potential hemorrhage. Option D, burning urination, is unrelated to the diagnosis of placenta previa and does not pose an immediate threat to the client's life. Educationally, understanding the priority of reporting critical findings in obstetric emergencies like placenta previa is crucial for nurses caring for pregnant clients. This question highlights the importance of recognizing potentially life-threatening situations and acting promptly to ensure the safety and well-being of both the mother and the baby.
Question 2 of 5
A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture lines. How should the nurse respond?
Correct Answer: A
Rationale: The correct answer is A) That's called caput succedaneum. It will absorb and cause no problems. Caput succedaneum is a common condition in newborns characterized by swelling on the baby's head due to pressure during birth. It typically resolves on its own without intervention. Option B is incorrect because a cephalohematoma, not caput succedaneum, is a collection of blood between the skull and periosteum. Unlike caput succedaneum, a cephalohematoma may take weeks to months to resolve as the body reabsorbs the blood. Option C is incorrect because cephalohematoma does not directly cause jaundice. Jaundice is usually a result of elevated bilirubin levels and is not directly related to a cephalohematoma. Option D is incorrect because caput succedaneum does not require drainage. It is a self-limiting condition that resolves as the baby's body reabsorbs the excess fluid. In an educational context, it is crucial for nurses to be able to differentiate between common newborn conditions like caput succedaneum and cephalohematoma to provide accurate information and reassurance to new parents. Understanding these conditions helps nurses promote parental education and alleviate unnecessary concerns regarding their newborn's health.
Question 3 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 4 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 5 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.