ATI RN
Pregnancy Assessment Questions Questions
Question 1 of 5
A mother, 39 weeks’ gestation, is admitted to the labor suite with rupture of membranes 15 minutes earlier and contractions q 8 minutes × 30 seconds. On vaginal exam, the cervix is 4 cm dilated and 80% effaced, and the station is –2. The baby is found to be in the LSP position. The fetal heart rate is 144 with average variability and variable decelerations. Which of the following complications of labor must the nurse assess this client for at this time?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Prolapsed cord. A prolapsed cord is a serious obstetrical emergency that occurs when the umbilical cord descends through the cervix alongside or ahead of the presenting part of the fetus. This can lead to cord compression, compromising fetal blood flow and oxygenation, resulting in fetal distress or even death. Option A) Precipitous delivery is incorrect because while the labor is progressing, there is no indication that delivery will be unusually rapid in this case. Option B) Chorioamnionitis is less likely at this moment as the focus should be on the immediate obstetric emergency of a prolapsed cord. Option C) Uteroplacental insufficiency is not the primary concern in this scenario as the fetal heart rate with average variability and variable decelerations suggests ongoing oxygenation to the fetus. Educationally, understanding obstetric emergencies like prolapsed cord is crucial for nurses and healthcare providers working in labor and delivery settings. Prompt recognition and intervention are essential to prevent adverse outcomes for both the mother and the baby. This case highlights the importance of critical thinking and quick decision-making skills in managing emergent situations during labor and delivery.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse in the obstetrician’s office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A - the African American, 15 years old, with newly diagnosed gestational diabetes. The reason for this choice is that African American women have a higher risk of preterm birth compared to other ethnic groups. Additionally, gestational diabetes is a risk factor for preterm labor. Therefore, this client requires close monitoring and education on the signs and symptoms of preterm labor. Option B, the Asian American with a history of previous term pregnancies, is less likely to be at high risk for preterm labor based on this information. Option C, the Jewish client who is a working professional, does not have any specific risk factors mentioned that would increase her likelihood of preterm labor. Option D, the Mormon client who recently moved, also does not present any specific risk factors for preterm labor based on the information provided. Educationally, this question highlights the importance of understanding risk factors for preterm labor in prenatal care. It emphasizes the need for individualized care based on factors such as ethnicity, medical history, and social circumstances to provide optimal care for pregnant clients. By reviewing and understanding these risk factors, nurses can better identify clients who may be at higher risk for preterm labor and provide appropriate education and monitoring.