ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences
Correct Answer: C
Rationale: The correct answer is C because a trickle of fluid from the vagina at 40 weeks' gestation could indicate the rupture of membranes, which is a sign of impending labor. This warrants immediate evaluation to assess the status of the amniotic sac and the need for monitoring or intervention. Explanation for other choices: A: Increased fetal movement is a normal sign of fetal well-being and not a reason for immediate evaluation. B: Irregular contractions for 1 hour may not necessarily indicate active labor, so immediate evaluation is not needed. D: Thick pink or dark red vaginal mucus may indicate bloody show, which can be a sign of labor starting, but it is not as urgent as a potential rupture of membranes.
Question 2 of 5
Which clinical finding would be an indication to the nurse that the fetus may be compromised?
Correct Answer: D
Rationale: The correct answer is D. Meconium-stained amniotic fluid indicates fetal distress due to possible hypoxia. Meconium in the fluid can lead to meconium aspiration syndrome, a serious condition. The other choices are incorrect because active fetal movements (A) and a fetal heart rate in the 140s (B) are normal signs of fetal well-being. Contractions lasting 90 seconds (C) could indicate labor progress but do not necessarily indicate fetal compromise.
Question 3 of 5
During labor a vaginal examination should be performed only when necessary because of the risk of
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection. Step 2: Infections can be harmful to both the mother and the baby. Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection. Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
Question 4 of 5
The nurse thoroughly dries the infant immediately after birth primarily to
Correct Answer: A
Rationale: The correct answer is A because drying the infant helps reduce heat loss through evaporation, preventing hypothermia. Wet skin can lead to rapid heat loss. This is critical for newborns who are at risk of temperature instability. Choice B is incorrect because drying the infant is not primarily done to stimulate crying and lung expansion. Choice C is incorrect because drying does not increase blood supply to the hands and feet. Choice D is incorrect because maternal blood is typically cleared from the infant's skin through other means, not primarily by drying.
Question 5 of 5
Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Fluid volume deficit (FV) related to fluid loss during labor and birth process. This diagnosis takes priority because dehydration can lead to serious complications for the mother and the baby. Inadequate fluid intake during labor can result in decreased blood volume, affecting both maternal and fetal circulation. This can lead to fetal distress and maternal hypotension. Choice B, fatigue related to length of labor, is important but not as critical as fluid volume deficit, as addressing dehydration is more urgent to prevent complications. Choice C, acute pain related to increased intensity of contractions, is also important but can be managed with pain relief measures, whereas fluid volume deficit requires immediate action. Therefore, it is not the priority at this moment. In summary, addressing fluid volume deficit is the priority as it directly impacts the well-being of both the mother and the baby during labor and birth, while the other options can be addressed once the dehydration issue is resolved.