ATI RN
Maternal Monitoring Questions
Question 1 of 5
A nurse is caring for a pregnant patient who is at 40 weeks gestation and reports leaking clear fluid. What is the nurse's priority action?
Correct Answer: D
Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.
Question 2 of 5
A pregnant patient reports experiencing dizziness and fainting when standing up quickly. What is the nurse's most appropriate response?
Correct Answer: D
Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting. A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension. B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects. C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.
Question 3 of 5
A nurse is caring for a pregnant patient who is at 28 weeks gestation and has a history of hypertension. Which of the following interventions is the most appropriate to prevent complications?
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure regularly and check for protein in the urine. This is the most appropriate intervention because the patient has a history of hypertension, which can lead to complications like preeclampsia. Regular blood pressure monitoring and urine protein checks are essential in detecting early signs of preeclampsia, allowing for timely intervention to prevent complications. Choice A: Encouraging the patient to increase salt intake would worsen hypertension and increase the risk of complications. Choice C: Increasing physical activity and exercise may not be safe for a pregnant patient with hypertension and can potentially raise blood pressure. Choice D: Limiting fluid intake can lead to dehydration and is not recommended during pregnancy, especially with a history of hypertension.
Question 4 of 5
A nurse is assessing a 26-week pregnant patient who is concerned about stretch marks. Which of the following interventions should the nurse suggest?
Correct Answer: B
Rationale: The correct answer is B because stretch marks are primarily influenced by genetics and skin elasticity. Moisturizing the skin can help reduce discomfort associated with stretch marks but cannot prevent them entirely. A is incorrect because over-the-counter creams are not proven to prevent stretch marks. C is incorrect because while some vitamins may promote skin health, they cannot completely prevent stretch marks. D is incorrect because while staying hydrated and exercising are important for overall health, they cannot guarantee the prevention of stretch marks.
Question 5 of 5
A nurse is assessing a pregnant patient who is at 34 weeks gestation and reports swelling in the legs and feet. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 34 weeks gestation, swelling in the legs and feet can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. The priority action is to assess for signs of preeclampsia, as it can lead to severe complications for both the mother and the baby. Monitoring blood pressure is crucial in identifying preeclampsia early. Choice B is incorrect because while elevating the feet may provide some relief from swelling, it does not address the potential underlying issue of preeclampsia. Choice C is incorrect because administering a diuretic without assessing for preeclampsia can be dangerous and potentially harmful to the patient and the baby. Choice D is incorrect because reducing fluid intake can lead to dehydration, which is not a recommended approach in pregnancy without proper assessment and guidance from healthcare providers.