ATI RN
Advanced Maternal Age Monitoring Questions
Question 1 of 5
A laboring person on oxytocin for induction of labor should have continuous monitoring of the fetal heart rate. How often should the nurse assess the fetal heart rate?
Correct Answer: B
Rationale: The correct answer is B: every 15 minutes. Continuous monitoring of the fetal heart rate is crucial during labor induction with oxytocin to promptly detect any signs of fetal distress. Assessing the fetal heart rate every 15 minutes allows for frequent monitoring to ensure the baby's well-being and timely intervention if needed. Assessing every 30 minutes (choice A) may not provide adequate monitoring frequency, every 5 minutes (choice C) is too frequent and may not be practical, and every 1 hour (choice D) is too long of an interval between assessments, potentially missing important changes in fetal status.
Question 2 of 5
A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
Question 3 of 5
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.
Question 4 of 5
What is the priority intervention for a laboring person with a suspected uterine rupture?
Correct Answer: B
Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation. Incorrect choices: A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial. C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications. D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.
Question 5 of 5
Which of the following is the most important nursing intervention for a laboring person who is receiving oxytocin for induction of labor?
Correct Answer: B
Rationale: The correct answer is B: monitor fetal heart rate continuously. This is crucial because oxytocin can cause uterine hyperstimulation leading to fetal distress. Continuous monitoring allows for early detection of fetal compromise. Monitoring for signs of uterine hyperstimulation (A) is important but secondary to fetal well-being. Emotional support (C) and encouraging ambulation (D) are beneficial but not as critical as ensuring fetal safety during oxytocin administration.