A patient at 37 weeks gestation is admitted with ruptured membranes. What is the first priority action for the nurse?

Questions 91

ATI RN

ATI RN Test Bank

Maternal Fetal Monitoring Questions

Question 1 of 5

A patient at 37 weeks gestation is admitted with ruptured membranes. What is the first priority action for the nurse?

Correct Answer: B

Rationale: The correct answer is B: Check for cord prolapse. This is the first priority action because a prolapsed cord is a life-threatening emergency that requires immediate intervention to prevent fetal hypoxia and distress. The nurse should quickly assess for cord presentation by performing a vaginal exam and relieving pressure on the cord if present. Incorrect choices: A: Assess for signs of infection - While infection is a concern with ruptured membranes, it is not the immediate priority over checking for cord prolapse. C: Perform a vaginal exam to assess cervical dilation - Assessing cervical dilation can wait until after ruling out cord prolapse. D: Perform a vaginal examination to check for fetal descent - Fetal descent assessment is not urgent compared to checking for cord prolapse in this scenario.

Question 2 of 5

A woman who has had multiple cesarean sections is in labor. What is the most important complication to monitor for?

Correct Answer: A

Rationale: Correct Answer: A: Uterine rupture Rationale: 1. History of multiple cesarean sections increases the risk of uterine rupture. 2. Uterine rupture is a life-threatening complication for both mother and baby. 3. Signs include sudden severe abdominal pain, fetal distress, and hemodynamic instability. 4. Immediate intervention is crucial to prevent adverse outcomes. Summary: B: Precipitous labor - Quick labor is not specifically associated with multiple cesarean sections. C: Maternal hypotension - Important but not the most critical complication in this scenario. D: Fetal malpresentation - While important, it is not the most immediate concern compared to uterine rupture.

Question 3 of 5

The nurse is caring for a 23-year-old patient who arrives at the clinic for a pregnancy test. The test confirms the patient is pregnant. The patient states, 'I do not need to stop smoking my electronic cigarette because it will not harm my baby.' Which is the best response by the nurse?

Correct Answer: B

Rationale: The correct answer is B: Tobacco products, including electronic cigarettes, should not be used during pregnancy due to risking nicotine toxicity. Rationale: 1. Nicotine from electronic cigarettes can cross the placenta, affecting fetal development. 2. Nicotine exposure during pregnancy is associated with adverse outcomes like low birth weight and preterm birth. 3. The best practice during pregnancy is to avoid all tobacco products, including electronic cigarettes. Summary: A: Incorrect. Electronic cigarettes can harm the fetus due to nicotine exposure. C: Incorrect. FDA does not consider electronic cigarettes safe during pregnancy. D: Incorrect. Harm from electronic cigarettes is not limited to the first trimester.

Question 4 of 5

A nursing student is asked to set goals that will decrease the fetal death outcomes during delivery. What guidelines will the nursing student use to assist in setting her goals?

Correct Answer: B

Rationale: The correct answer is B: Healthy People 2020. This is because Healthy People 2020 provides specific objectives related to maternal and child health, including reducing fetal death outcomes during delivery. The goals and targets outlined in Healthy People 2020 are evidence-based and nationally recognized, making it a reliable guide for setting healthcare goals. A: WHO Maternal care guidelines focus more broadly on global maternal health issues and may not provide specific goals related to reducing fetal death outcomes during delivery. C: AWHONN white papers may offer valuable insights and recommendations, but they are not as comprehensive or widely recognized as the goals outlined in Healthy People 2020. D: State Practice Acts govern the scope of practice for healthcare providers in a specific state, but they do not typically include specific goals related to reducing fetal death outcomes during delivery.

Question 5 of 5

A pregnant woman who is 28 weeks gestation reports that she feels dizzy and faint when she stands up. What should the nurse instruct the patient to do?

Correct Answer: D

Rationale: The correct answer is D, instructing the pregnant woman to get up slowly and avoid standing for long periods. This is because during pregnancy, blood pressure can drop when standing up quickly, leading to dizziness and fainting. Getting up slowly allows the body to adjust gradually, preventing a sudden drop in blood pressure. Standing for long periods can worsen these symptoms, so it is important to avoid prolonged standing. A: Lying down flat on the back immediately can worsen symptoms in this case by reducing blood flow to the brain. B: Standing up quickly can exacerbate dizziness and fainting by causing a sudden drop in blood pressure. C: Drinking a large amount of water may not address the underlying issue of postural hypotension and could potentially worsen symptoms by increasing blood volume without addressing the drop in blood pressure.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days

Similar Questions