ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A nursing priority during admission of a laboring patient who has not had prenatal care is
Correct Answer: B
Rationale: The correct answer is B: identifying labor risk factors. This is a priority because it helps in assessing potential complications and planning appropriate care. Obtaining admission labs (A) can be important but not the top priority. Discussing birth plan choices (C) can wait until after assessing risk factors. Explaining the importance of prenatal care (D) is not the immediate concern during labor admission. Identifying labor risk factors is crucial for ensuring the safety and well-being of both the mother and the baby.
Question 2 of 5
After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?
Correct Answer: D
Rationale: The correct answer is D. Edema and discoloration of the labia and perineum indicate the presence of a potential vaginal wall hematoma. This is because hematoma can cause swelling and bruising in the affected area. Bright red lochia and a firm fundus are more indicative of postpartum hemorrhage, not vaginal wall hematoma. Choices A and C are not directly related to the presence of a vaginal wall hematoma. Mild, intermittent perineal pain (Choice B) is non-specific and can be present in various postpartum conditions. Thus, option D is the most relevant indicator of a potential vaginal wall hematoma in this scenario.
Question 3 of 5
A maternal indication for the use of vacuum extraction is
Correct Answer: B
Rationale: The correct answer is B: maternal exhaustion. Vacuum extraction may be indicated when the mother is too exhausted to continue pushing, as it can assist in the delivery process. A wide pelvic outlet (choice A) may facilitate delivery but is not a specific indication for vacuum extraction. A history of rapid deliveries (choice C) does not necessarily require vacuum extraction. Failure to progress past 0 station (choice D) may indicate other interventions like cesarean section rather than vacuum extraction. Therefore, the most appropriate indication for vacuum extraction in this scenario is maternal exhaustion.
Question 4 of 5
Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
Correct Answer: A
Rationale: The correct action is to assess the infant for signs of trauma (Choice A) because forceps-assisted birth can increase the risk of injury to the infant. By assessing for signs of trauma promptly, the nurse can identify any potential issues and initiate necessary interventions. Choice B is incorrect because measuring the circumference of the infant's head is not necessary immediately after forceps-assisted birth. Choice C is incorrect as applying a cold pack to the infant's scalp is not indicated unless there is a specific medical reason for it. Choice D is incorrect because giving prophylactic antibiotics to the infant is not a standard practice following forceps-assisted birth unless there is a specific indication for infection prevention.
Question 5 of 5
The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?
Correct Answer: D
Rationale: The correct answer is D because a patient with previous surgery in the upper uterus is at risk for uterine rupture with prostaglandin use. Previous surgery in the upper uterus may weaken the uterine wall, increasing the risk of complications such as uterine rupture during cervical ripening. A: Bishop's score of 5 indicates a moderate readiness for induction, making vaginal prostaglandin appropriate. B: 42 weeks of gestation is considered post-term, where cervical ripening is often needed. C: Previous low transverse cesarean birth is not a contraindication for prostaglandin use for cervical ripening.