ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A patient in active labor is experiencing hypotension after receiving an epidural block. What is the nurse's first action?
Correct Answer: C
Rationale: The correct answer is C. Placing the patient in a side-lying position is the first action because it helps to improve venous return, cardiac output, and blood pressure by increasing blood flow to the heart and brain. This can help alleviate hypotension associated with epidural block. Elevating the legs (choice B) may not be as effective in improving blood flow in this situation. Administering a fluid bolus (choice A) may be necessary but should not be the initial action. Notifying the anesthesiologist (choice D) is important, but addressing the patient's immediate physiological needs should come first.
Question 2 of 5
Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?
Correct Answer: D
Rationale: The correct answer is D. Saturation of two perineal pads in 4 hours is an indication of hemorrhage postpartum. This is because excessive bleeding after delivery can lead to soaking through pads quickly. A: Elevated pulse rate can be a sign of shock but not specific to hemorrhage. B: Elevated blood pressure is not a typical sign of hemorrhage. C: A firm fundus at the midline is a normal finding postpartum and not indicative of hemorrhage.
Question 3 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 4 of 5
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions. A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period. C is incorrect as last food intake and cultural practices are not the most critical assessments during labor. D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
Question 5 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.