ATI RN
Maternal Monitoring During Labor Questions
Question 1 of 5
A nurse is caring for a 38-week pregnant patient who is experiencing a decrease in fetal movement. Which of the following should be the nurse's first action?
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink a cold beverage and lie down. This is the correct action as it promotes fetal movement by stimulating the baby with a change in temperature and position. It is a non-invasive and immediate measure that can be taken by the patient herself. Choice B is incorrect because waiting 24 hours could delay necessary intervention if the fetus is in distress. Choice C is incorrect as ordering an ultrasound may not be the most immediate or necessary action at this point. Choice D is incorrect as calling the healthcare provider immediately may not be necessary if the issue can be resolved by the patient changing her position and trying to stimulate fetal movement first.
Question 2 of 5
The nurse is caring for a pregnant patient who is 35 weeks gestation and reports sharp abdominal pain and decreased fetal movement. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Call the healthcare provider immediately and prepare for further assessment. This is the priority action because sharp abdominal pain and decreased fetal movement at 35 weeks gestation could indicate a serious complication such as placental abruption or fetal distress. Calling the healthcare provider promptly allows for timely intervention and assessment to ensure the safety of both the mother and the baby. Encouraging the patient to drink water and rest (choice A) may not address the underlying issue. Monitoring fetal heart rate and performing a nonstress test (choice C) may be important but not as immediate as contacting the healthcare provider. Asking the patient to lie on her left side and wait for symptoms to resolve (choice D) delays necessary medical evaluation and intervention.
Question 3 of 5
The nurse is caring for a pregnant patient who is 30 weeks gestation and has a BMI of 32. Which of the following complications should the nurse monitor for more closely?
Correct Answer: A
Rationale: The correct answer is A: Gestational diabetes and preeclampsia. A pregnant patient with a BMI of 32 is considered obese, which increases the risk of developing gestational diabetes and preeclampsia. Gestational diabetes is more likely in overweight women and can lead to complications for both the mother and baby. Preeclampsia is also more common in obese women and can result in high blood pressure and organ damage. Monitoring for these complications is crucial to ensure the well-being of both the mother and baby. Incorrect choices: B: Hyperemesis gravidarum and miscarriage - These complications are not directly related to the patient's weight or BMI. C: Iron-deficiency anemia and urinary tract infections - While these complications can occur in pregnancy, they are not specifically associated with the patient's BMI. D: Gestational hypertension and placenta previa - While gestational hypertension can be a concern in obese patients, placenta previa is not directly linked to
Question 4 of 5
A pregnant patient is at 25 weeks gestation and is concerned about her risk of preterm labor. Which of the following symptoms should the nurse educate the patient to report immediately?
Correct Answer: C
Rationale: The correct answer is C: Painful, regular contractions. At 25 weeks gestation, experiencing painful, regular contractions could indicate preterm labor, which requires immediate medical attention to prevent premature birth. Mild back pain and cramping (choice A) are common in pregnancy and may not necessarily indicate preterm labor. Increased vaginal discharge (choice B) is also common in pregnancy and not typically a sign of preterm labor. Feeling of pelvic pressure after physical activity (choice D) is common due to the growing uterus and ligament stretching, but it is not a definitive sign of preterm labor unless accompanied by other symptoms like contractions.
Question 5 of 5
A pregnant patient is at 32 weeks gestation and reports a sudden headache and visual disturbances. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B because sudden headache and visual disturbances in a pregnant patient at 32 weeks gestation could indicate preeclampsia. Assessing blood pressure and checking for protein in the urine are crucial steps in diagnosing preeclampsia, a serious condition that requires immediate medical attention to prevent complications for both the mother and baby. Encouraging rest, administering pain medication, or suggesting caffeinated beverages may mask symptoms but not address the underlying issue of preeclampsia. Therefore, prompt assessment and monitoring of blood pressure and urine protein levels are essential in this scenario.