ATI RN
Advanced Maternal Age Monitoring Questions
Question 1 of 5
A nurse is assessing a postpartum person for signs of deep vein thrombosis (DVT). What is the most common sign of DVT in the postpartum period?
Correct Answer: A
Rationale: The correct answer is A: Swelling and redness of the calf. Postpartum women are at a higher risk for DVT due to hormonal changes and immobility. Swelling and redness in the calf indicate possible DVT as blood clots can cause inflammation and blockage in the veins. Pain in the lower leg (B) is a common symptom but not the most specific for DVT. Heat intolerance (C) and cold intolerance (D) are not typically associated with DVT and are unrelated symptoms in this context.
Question 2 of 5
A nurse is preparing to administer a postpartum tetanus shot. What is the most important action before administering the shot?
Correct Answer: C
Rationale: Rationale: C is correct because assessing for uterine atony is crucial before administering a postpartum tetanus shot to ensure no postpartum hemorrhage risk. Uterine atony can lead to excessive bleeding, which can be exacerbated by the tetanus shot. Summary: A - Verifying immunization status is important but not the most immediate action. B - Assessing blood pressure is important but not directly related to the risk of postpartum hemorrhage. D - Preparing for a cesarean section is not necessary for administering a postpartum tetanus shot.
Question 3 of 5
A nurse is caring for a postpartum person who is experiencing a boggy uterus. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: perform uterine massage. This is the priority intervention for a boggy uterus to prevent postpartum hemorrhage by promoting uterine contraction and reducing bleeding. Uterine massage helps the uterus to firm up and expel clots. Early ambulation (B) and positioning (C) can support recovery but do not directly address the boggy uterus. Performing a pelvic exam (D) is not necessary for managing a boggy uterus and may even exacerbate bleeding.
Question 4 of 5
A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?
Correct Answer: C
Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically. Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.
Question 5 of 5
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head crowns?
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of perineal tearing and ensuring a controlled birth. Applying too much pressure can cause trauma to the mother and baby. Incorrect choices: B is premature, as shoulder delivery should only be done after the head and shoulders are delivered. C is not the most important action at crowning. D is not necessary at this specific stage of delivery.