ATI RN
Maternity Heartbeat Monitor Questions
Question 1 of 5
A pregnant patient at 28 weeks gestation is experiencing severe swelling in her hands and feet. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action to take first is to assess the patient's blood pressure and check for signs of preeclampsia (Answer A). Preeclampsia is a serious condition characterized by high blood pressure and signs of organ dysfunction. In this scenario, the patient's severe swelling could be indicative of preeclampsia, which poses a risk to both the mother and the fetus. By assessing blood pressure and looking for other signs of preeclampsia, the nurse can determine the urgency of the situation and take appropriate actions to manage the condition. Encouraging leg elevation and rest (Answer B) may help alleviate some symptoms but does not address the underlying cause of the swelling. Monitoring urine output (Answer C) is important for overall assessment but does not address the immediate concern of potential preeclampsia. Scheduling an ultrasound (Answer D) is not the priority in this situation as it does not provide information about the patient's current condition and does not address the
Question 2 of 5
A pregnant patient at 32 weeks gestation reports increased pressure in the pelvic area and mild cramping. What should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A: The fetal heart rate and signs of labor. At 32 weeks gestation, any pelvic pressure and cramping could be indicative of preterm labor, which is a critical concern. Assessing the fetal heart rate can help determine fetal well-being and signs of distress. Monitoring for signs of labor such as contractions, cervical changes, and rupture of membranes is essential for timely intervention. Choice B: Assessing blood pressure and urine for protein is important in monitoring for preeclampsia, but it is not the priority in this case where signs of preterm labor are reported. Choice C: Vaginal discharge or bleeding could indicate various conditions, but in this scenario, the focus should be on ruling out preterm labor first. Choice D: Dietary intake and hydration status are important aspects of prenatal care, but they are not the priority when assessing a pregnant patient reporting pelvic pressure and cramping at 32 weeks gestation.
Question 3 of 5
A pregnant patient at 28 weeks gestation reports feeling nauseated and vomiting after meals. What is the most appropriate action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Recommend the patient eat smaller, more frequent meals and avoid greasy foods. This is because smaller, more frequent meals can help alleviate nausea and vomiting during pregnancy by preventing the stomach from becoming too full. Greasy foods can exacerbate nausea, so avoiding them is beneficial. A: Encouraging large meals less frequently can worsen symptoms by overwhelming the digestive system. C: Resting after meals may not directly address the underlying cause of nausea and vomiting. D: Avoiding all foods can lead to inadequate nutrition for both the patient and the developing fetus. In summary, choice B is the most appropriate as it addresses the symptoms effectively and promotes better nutrition during pregnancy.
Question 4 of 5
A pregnant patient at 34 weeks gestation is concerned about swelling in her hands, feet, and face. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. At 34 weeks gestation, swelling in the hands, feet, and face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and proteinuria. Monitoring blood pressure is crucial to identify any preeclampsia development. Preeclampsia can lead to complications for both the mother and the baby if left untreated. Other choices are incorrect because B may provide temporary relief but does not address the underlying concern, C should not be done without confirming the diagnosis, and D focuses on fluid intake and sodium intake but does not address the need to assess for preeclampsia.
Question 5 of 5
A pregnant patient is 26 weeks gestation and reports difficulty breathing when lying flat. What should the nurse recommend?
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm. At 26 weeks gestation, the uterus can compress the inferior vena cava when lying flat on the back, leading to decreased blood return to the heart and reduced cardiac output, causing difficulty breathing. Sleeping on the left side helps improve circulation by reducing pressure on the vena cava, enhancing blood flow and oxygenation to the fetus and mother. Incorrect options: B: Recommending sleeping in a fully reclined position may not alleviate the compression on the vena cava and could potentially worsen the patient's symptoms. C: Administering oxygen may help with oxygenation but does not address the underlying issue of vena cava compression due to the growing uterus. D: Instructing the patient to lie flat on her back can exacerbate the issue by further compressing the vena cava, worsening breathing difficulties.