ATI RN
Pregnancy Assessment Questions Questions
Question 1 of 5
A client, who is 6 hours post–vaginal delivery, has a BP of 150/110. Her last 4 BP readings were: 114/88, 120/80, 134/86, 140/90. Which of the following questions should the nurse ask the client at this time?
Correct Answer: D
Rationale: In this scenario, the correct question the nurse should ask the client is option D) "Do you have a headache or blurring of your vision?". This is the correct choice because the client's elevated blood pressure of 150/110, especially when compared to her previous readings, could be indicative of postpartum preeclampsia, a serious condition characterized by high blood pressure and often accompanied by headaches and visual disturbances. Option A) "Have you had a bowel movement since delivery?" is incorrect because it is not directly related to the client's elevated blood pressure and does not address the urgent need to assess for signs of preeclampsia. Option B) "Is there anything that is making you anxious about the baby?" is also incorrect as it does not address the immediate health concern of the client's high blood pressure and potential signs of preeclampsia. Option C) "When you last went to the bathroom were you bleeding heavily?" is not the most appropriate question at this time as it does not directly address the client's current blood pressure and symptoms that could indicate a serious complication like preeclampsia. In an educational context, it is crucial for nurses to be able to recognize signs and symptoms of postpartum complications, such as preeclampsia, and to ask targeted questions to assess and manage these conditions promptly. Understanding the significance of changes in vital signs and knowing which questions to ask can lead to early detection and intervention, ultimately improving maternal and neonatal outcomes.
Question 2 of 5
The nurse is caring for a client and her partner who just birthed a 33-week fetal demise. Which of the following actions by the nurse is appropriate at this time?
Correct Answer: C
Rationale: In this scenario, the most appropriate action by the nurse is option C: Ask the couple if they would like to hold their baby. This choice demonstrates compassionate and patient-centered care during a highly sensitive and emotionally challenging situation. Allowing the parents the opportunity to hold their baby provides them with a chance to create memories and say goodbye, which can aid in their grieving process and facilitate closure. Option A is incorrect because moving the woman to a medical unit may not address the emotional needs of the couple during this difficult time. Option B is also inappropriate as refraining from discussing the loss with the couple can lead to feelings of isolation and lack of support. Option D is not the priority at this moment as obtaining a milk suppressant for the mother does not address the immediate emotional needs of the couple. Educationally, this question highlights the importance of providing holistic care to patients, especially in emotionally charged situations like perinatal loss. It emphasizes the significance of communication, empathy, and sensitivity in nursing practice, particularly when caring for individuals experiencing grief and loss.
Question 3 of 5
During a postpartum examination, the nurse notes that a client’s left calf is warm and swollen. Which of the following actions by the nurse is appropriate at this time?
Correct Answer: A
Rationale: In this scenario, option A is the correct choice for the nurse to take - notifying the client's physician. This symptom of a warm, swollen left calf could indicate deep vein thrombosis (DVT), a serious condition where a blood clot forms in a deep vein. It is crucial for the physician to assess the client promptly to prevent potential complications like pulmonary embolism. Option B, teaching the client to massage her leg, is incorrect as massaging a suspected DVT can dislodge the clot and lead to serious consequences. Option C, applying ice packs, is also inappropriate as cold therapy can further increase the risk of clot formation. Option D, encouraging ambulation, is contraindicated as it can potentially dislodge the clot and lead to embolism. Educationally, this question highlights the importance of recognizing signs of DVT in postpartum women, who are at higher risk due to factors like immobility during childbirth. Nurses need to be vigilant in assessing such symptoms and understanding the appropriate interventions to ensure the safety and well-being of their patients. Early detection and intervention in such cases are critical to prevent adverse outcomes.
Question 4 of 5
Without doing a vaginal examination, a nurse concludes that a primigravida, who has received no medications during her labor, is in transition. Which of the following signs/symptoms would lead a nurse to that conclusion?
Correct Answer: B
Rationale: In pharmacology, understanding the signs and symptoms of labor progression is crucial for nurses to provide appropriate care during pregnancy. In this scenario, option B is correct because yelling at her partner and vomiting are indicative of the transition phase of labor. During transition, women often exhibit signs of emotional and physical intensity, such as irritability and nausea, which are reflected in this response. Option A, where the woman fell asleep during a contraction, is incorrect because it suggests a lack of awareness and responsiveness, which are not typical of the transition phase. Option C, where the woman laughed at something on the television, is also incorrect as it indicates a relaxed and possibly distracted state, which is not characteristic of transition. Option D, where the woman began pushing with each contraction, is incorrect because pushing typically occurs during the second stage of labor, not during transition. It is important for nurses to recognize the signs of each stage of labor to provide appropriate support and interventions to ensure the well-being of both the mother and the baby.
Question 5 of 5
The mother of a neonate with Down syndrome wishes to breastfeed. Which of the following considerations should the nurse make in relation to the mother’s wishes?
Correct Answer: D
Rationale: The correct answer is option D: "The baby will likely have a weak suck due to congenitally poor muscle tone." In the context of a neonate with Down syndrome, it is important to consider the potential implications of the condition on breastfeeding. Infants with Down syndrome commonly have hypotonia, or low muscle tone, which can affect their ability to suck effectively. This can lead to challenges in latching onto the breast and extracting milk efficiently. Option A is incorrect because while feeding expressed breast milk via a bottle may be an alternative, it does not address the specific issue of weak suck related to Down syndrome. Option B is incorrect as there is no evidence to support the statement that Down syndrome babies consume more calories than unaffected neonates. In fact, individual calorie needs vary based on factors like weight and growth. Option C is incorrect as the weight of the neonatal head is not a primary factor to consider in this scenario. Positioning during breastfeeding is important but is not directly related to the baby having Down syndrome. Educationally, understanding the unique challenges faced by infants with Down syndrome in breastfeeding is crucial for healthcare providers to provide appropriate support and guidance to mothers. By recognizing the potential impact of hypotonia on the infant's ability to suck effectively, nurses can offer tailored strategies to optimize the breastfeeding experience for both the mother and the baby.