ATI RN
Maternal Monitoring During Labor Questions
Question 1 of 5
A patient who is 40 weeks pregnant and is in labor suddenly complains of a severe headache and blurry vision. What should the nurse assess for?
Correct Answer: A
Rationale: The correct answer is A: Preeclampsia. In this scenario, the sudden onset of severe headache and blurry vision in a pregnant woman in labor are indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and signs of organ damage. The nurse should assess for other symptoms of preeclampsia such as hypertension, proteinuria, edema, and epigastric pain. Preeclampsia can lead to eclampsia, seizures, and life-threatening complications for both the mother and the baby if not promptly managed. Summary: B: Fetal distress - Not the priority assessment when the mother is experiencing symptoms indicative of a serious maternal condition like preeclampsia. C: Uterine rupture - Symptoms are not suggestive of uterine rupture, which typically presents with severe abdominal pain, vaginal bleeding, and signs of shock. D: Placenta previa - Symptoms are not consistent with placenta previa, which typically
Question 2 of 5
A patient in labor is at 6 cm dilation and requests an epidural. What is the most appropriate response from the nurse?
Correct Answer: B
Rationale: The correct answer is B: "You can have the epidural now since you are in active labor." At 6cm dilation, the patient is typically considered to be in active labor, making it an appropriate time to offer an epidural for pain relief. Administering the epidural at this stage can help manage the pain effectively and provide relief during the remainder of labor. Other choices are incorrect because waiting until 8cm dilation (Choice A) may cause unnecessary suffering, administering after the second stage (Choice C) is too late for pain relief, and giving it during the latent phase (Choice D) is not ideal as the patient may not be in active labor yet.
Question 3 of 5
A patient who has been in labor for several hours is now fully dilated and ready to push. What is the first action the nurse should take?
Correct Answer: C
Rationale: The correct answer is C: Assess the fetal heart rate. This is important to ensure the baby's well-being during the pushing phase. By monitoring the fetal heart rate, the nurse can detect any signs of distress or complications, allowing for prompt intervention if needed. Encouraging the patient to push (A) is appropriate once the fetal well-being is confirmed. While preparing the delivery room (B) is important, it is not the immediate priority. Administering pain relief (D) can be considered after assessing the fetal heart rate and ensuring the baby's safety.
Question 4 of 5
A patient in labor who is 7 cm dilated requests pain relief. What is the most appropriate intervention at this time?
Correct Answer: A
Rationale: The correct answer is A: Administer an epidural block. At 7 cm dilation, the patient is in active labor and an epidural can provide effective pain relief without affecting the ability to push during the second stage of labor. Epidural blocks work by numbing the lower part of the body, reducing pain sensation while allowing the patient to remain alert and able to push effectively when the time comes. Non-pharmacological methods (B) may not provide sufficient relief at this stage. Narcotic analgesics (C) can pass through the placenta and affect the baby. Encouraging the patient to push (D) prematurely can lead to exhaustion and prolonged labor.
Question 5 of 5
The nurse is caring for a patient at 7 weeks gestation. The nurse suspects that a pregnant patient may have been using marijuana. With consent, the nurse confirms via urine drug screen. Which statement by the nurse is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Using marijuana while pregnant can have a negative effect on the neurological development of your baby. Rationale: 1. Marijuana use during pregnancy has been associated with adverse effects on the developing fetus, including potential negative impacts on neurological development. 2. The nurse's statement acknowledges the potential harm to the baby's neurological development, emphasizing the importance of avoiding marijuana during pregnancy. 3. This response focuses on providing essential information to the patient about the specific risks associated with marijuana use during pregnancy, highlighting the importance of making informed choices for the health of the baby. Summary: A: This choice makes assumptions about the patient's past behavior and does not provide essential information about the risks of marijuana use during pregnancy. B: This choice focuses on the timing of stopping marijuana use rather than addressing the potential harm to the baby's neurological development. D: This choice mentions miscarriage as a risk, which is not the primary concern associated with marijuana use during pregnancy.