ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A maternal indication for the use of vacuum extraction is
Correct Answer: B
Rationale: The correct answer is B: maternal exhaustion. Vacuum extraction may be indicated when the mother is too exhausted to continue pushing, as it can assist in the delivery process. A wide pelvic outlet (choice A) may facilitate delivery but is not a specific indication for vacuum extraction. A history of rapid deliveries (choice C) does not necessarily require vacuum extraction. Failure to progress past 0 station (choice D) may indicate other interventions like cesarean section rather than vacuum extraction. Therefore, the most appropriate indication for vacuum extraction in this scenario is maternal exhaustion.
Question 2 of 5
The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?
Correct Answer: D
Rationale: The correct answer is D because a patient with previous surgery in the upper uterus is at risk for uterine rupture with prostaglandin use. Previous surgery in the upper uterus may weaken the uterine wall, increasing the risk of complications such as uterine rupture during cervical ripening. A: Bishop's score of 5 indicates a moderate readiness for induction, making vaginal prostaglandin appropriate. B: 42 weeks of gestation is considered post-term, where cervical ripening is often needed. C: Previous low transverse cesarean birth is not a contraindication for prostaglandin use for cervical ripening.
Question 3 of 5
Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?
Correct Answer: B
Rationale: The correct answer is B: Symmetry of facial movements. Bruising over the cheeks can indicate potential nerve damage from the forceps birth. Assessing facial movements helps determine if there is any nerve injury affecting facial muscles. Presence of newborn reflexes (A) is important but not directly related to facial nerve injury. Caput and molding of the head (C) are more related to the birthing process and not specific to facial nerve assessment. Anterior and posterior fontanels (D) are important for assessing fontanelle closure but not specific to facial nerve evaluation.
Question 4 of 5
Following an external cephalic version, which assessment finding indicates a complication?
Correct Answer: C
Rationale: The correct answer is C: Deceleration of FHR to 88 bpm. This finding indicates fetal distress, a complication post external cephalic version. Deceleration of FHR suggests reduced oxygenation to the fetus. A: Onset of irregular contractions is a common post-procedure finding and not necessarily indicative of a complication. B: Maternal blood pressure of 110/70 mm Hg is within normal range and not directly related to a complication. D: Maternal pulse rate of 100 bpm is slightly elevated but not a specific indicator of a complication post external cephalic version.
Question 5 of 5
The labor nurse is developing a plan of care for a patient admitted in active labor with
Correct Answer: A
Rationale: The correct answer is A: On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). The priority nursing action for this patient is to assess the vital signs. The maternal heart rate, fetal heart rate, blood pressure, and temperature are crucial indicators of the patient's and the fetus's well-being during labor. Monitoring these vital signs helps the nurse detect any abnormalities or signs of distress promptly, allowing for timely intervention. Choice B, fetal acoustic stimulation, is not the priority at this stage as there are no indications in the question stem that suggest the need for this intervention. Choice C, assessing temperature every 2 hours, is not the priority as the patient's temperature is within normal range on admission. Choice D, changing absorption pads under her hips every 2 hours,