ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A patient in early labor is feeling anxious about the labor process. Which intervention would be most effective in reducing her anxiety?
Correct Answer: A
Rationale: The correct answer is A. Explanation of the stages of labor and what to expect can help the patient understand the process, reducing uncertainty and anxiety. This empowers the patient and promotes a sense of control. Encouraging breathing techniques (B) can help manage pain but may not address the underlying anxiety. Administering sedatives (C) should be a last resort due to potential side effects. Limiting visitors (D) can help reduce stress, but addressing the patient's anxiety requires more direct intervention.
Question 2 of 5
The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
Question 3 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 4 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 5 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.