ATI RN
Maternal Fetal Monitoring Questions
Question 1 of 5
A nurse is caring for a postpartum person who is experiencing a headache. What is the most likely cause of a postpartum headache?
Correct Answer: B
Rationale: The correct answer is B: Spinal headache. Postpartum spinal headaches are commonly caused by leakage of cerebrospinal fluid due to accidental dural puncture during epidural anesthesia. This can lead to severe headaches that worsen when sitting or standing. Eclampsia (A) presents with hypertension and seizures, not just headaches. Tension headaches (C) are typically stress-related and not specific to the postpartum period. Cluster headaches (D) are characterized by severe pain around the eye and are not commonly associated with childbirth.
Question 2 of 5
A nurse is preparing a laboring person for an epidural. What is the most important nursing intervention before the procedure?
Correct Answer: A
Rationale: The correct answer is A: Ensure informed consent is signed. Before any procedure, it is crucial to obtain informed consent to ensure the individual understands the risks, benefits, and alternatives. This protects their autonomy and ensures they are making an informed decision. Administering IV fluids (B) is important but not as critical as obtaining consent. Monitoring vital signs (C) is essential but not the most important step before the procedure. Administering pain relief (D) should only be done after ensuring informed consent and assessing the individual's pain level.
Question 3 of 5
A nurse is assisting with a vaginal delivery. What is the most important action to take when the fetal head begins to crown?
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent the baby from being born too quickly, reducing the risk of tearing for the mother. It also ensures a controlled delivery, decreasing the likelihood of complications such as shoulder dystocia. Administering pain relief (B) or analgesics (C) may be necessary but not the most crucial at this moment. Performing perineal massage (D) is beneficial for reducing the risk of tearing but is not as important as guiding the baby's head during crowning.
Question 4 of 5
A nurse is assisting with a vaginal delivery. What is the most important action when the fetal head begins to crown?
Correct Answer: A
Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent rapid delivery, reducing the risk of tearing and allowing the perineum to stretch gradually. It also helps control the delivery, ensuring a safe and controlled birth process. Performing perineal massage (B) is beneficial during the pushing stage but is not the most important action when the head crowns. Performing a vaginal exam (C) is unnecessary and may increase the risk of infection. Assisting with breathing exercises (D) is important during labor but not specifically when the head crowns.
Question 5 of 5
A pregnant woman states, “My husband hopes I will give him a boy because we have three girls.” What will the nurse explain to this woman?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.