ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin C drug, how should the nurse respond?
Correct Answer: A
Rationale: In this scenario, the correct response for the nurse is option A) "You may be at risk for having a spontaneous miscarriage." This is the most appropriate answer because misoprostol, a synthetic prostaglandin C drug used to treat peptic ulcers, is known to cause uterine contractions and can lead to miscarriage or preterm labor if used during pregnancy. Option B) "You may have an increased chance of having preeclampsia" is incorrect because misoprostol does not specifically increase the risk of preeclampsia. Option C) "This medication will have no effect on your unborn child" is also incorrect as misoprostol can indeed have serious effects on the pregnancy. Option D) "You may experience postpartum hemorrhaging after delivery" is not directly related to the use of misoprostol during pregnancy. Educationally, this question highlights the importance of understanding the potential risks associated with medications during pregnancy. Nurses should be aware of the teratogenic effects of certain drugs and provide accurate information to pregnant clients to ensure the safety of both the mother and the unborn child. This knowledge is crucial for effective antenatal care and counseling.
Question 2 of 5
The parents of a male newborns have signed an informed consent for circumcision. which intervention should the nurse implement upon completion of the circumcision?
Correct Answer: A
Rationale: In this scenario, the correct intervention is option A) Place petroleum gauze dressings on the site. This intervention is crucial for wound care post-circumcision as it helps protect the incision site from contamination and promotes healing. Option B) Wrap the infant in warm receiving blankets is not the most appropriate intervention after circumcision as it does not address the specific wound care needs of the circumcision site. Option C) Giving a PRN dose of liquid acetaminophen may be appropriate for pain management after circumcision, but it is not the immediate intervention needed post-procedure. Option D) Offering a pacifier dipped in glucose water is not recommended as the primary intervention after circumcision. This intervention does not address the wound care needs of the circumcision site and may not be appropriate for newborns. Educationally, it is important for nurses to understand the post-circumcision care protocol to ensure proper wound healing and prevent complications. Nurses should be knowledgeable about wound care, pain management, and comfort measures for newborns undergoing circumcision to provide safe and effective care.
Question 3 of 5
At 6 weeks gestation the rubella titer of a client medication indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?
Correct Answer: D
Rationale: The correct answer is D) Early postpartum within 72 hours of delivery. Administering the rubella vaccine early postpartum is crucial as it ensures protection for the mother before she conceives her next child. By vaccinating the mother in the early postpartum period, it helps prevent congenital rubella syndrome in future pregnancies. Option A) After the client stops breastfeeding is incorrect because delaying the vaccine until the client stops breastfeeding leaves her vulnerable to rubella infection during that period, potentially affecting future pregnancies. Option B) Immediately, at 6-weeks gestation to protect the fetus is incorrect because administering live vaccines during pregnancy is contraindicated due to the theoretical risk of harm to the fetus. Option C) After the client reaches 20-weeks gestation is incorrect because waiting until 20 weeks gestation may not provide adequate protection to the mother during the vulnerable period between pregnancies. Educationally, understanding the timing of rubella vaccination in the postpartum period is essential for healthcare providers working in maternity care to ensure optimal maternal and fetal health outcomes. It highlights the importance of proper timing in administering vaccines to protect both the mother and future pregnancies.
Question 4 of 5
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and cervix dialed 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C: Intensity, interval, and length of contractions. Monitoring these factors is crucial when managing hypotonic dystocia with an oxytocin drip. The nurse must assess the effectiveness of the medication in increasing the frequency, strength, and duration of contractions to progress labor. Option A (Clients hourly blood pressure) is incorrect as it is not the priority in this situation. While monitoring blood pressure is essential in pregnancy, in the context of managing hypotonic dystocia, assessing contractions is more pertinent. Option B (Preparation for emergency cesarean birth) is premature at this point as the first step in managing hypotonic dystocia is to attempt to augment labor with oxytocin. Cesarean birth should be considered if labor fails to progress despite oxytocin augmentation and other interventions. Option D (Checking the perineum for bulging) is not as critical as monitoring contractions in this case. Perineal assessment is important in the second stage of labor to determine fetal descent, but in the context of hypotonic dystocia, monitoring contractions takes precedence. Educationally, understanding the rationale behind monitoring contraction patterns in hypotonic dystocia helps students grasp the importance of timely and appropriate interventions in obstetric emergencies, promoting safe and effective maternal and fetal outcomes.
Question 5 of 5
A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client?
Correct Answer: C
Rationale: The correct answer is option C: "When there is no significant vaginal bleeding." This is the most important information for the nurse to provide the client because it indicates the status of the client's postpartum bleeding, which is a crucial aspect to monitor following delivery. Significant vaginal bleeding could be a sign of postpartum hemorrhage, a serious complication that requires immediate medical attention to prevent further complications or harm to the mother. Option A, "When ambulating to void does not cause dizziness," while important for the client's safety, is not as critical as monitoring for postpartum bleeding. Option B, "After the vitamin K injection is given to the baby," and Option D, "After the baby no longer demonstrates acrocyanosis," are related to the newborn's care and not directly relevant to the client's discharge readiness. In an educational context, this question emphasizes the importance of prioritizing postpartum assessment and teaching in maternity care. Nurses need to educate clients on postpartum warning signs, including excessive bleeding, to ensure optimal postpartum recovery and prevent complications. This scenario highlights the nurse's role in providing essential information to empower clients to make informed decisions about their health and well-being during the postpartum period.