ATI RN
External Maternal Monitoring Questions
Question 1 of 5
A pregnant patient at 30 weeks gestation is complaining of severe heartburn. What should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Eat smaller meals more frequently and avoid lying down after meals. This is the best recommendation for the pregnant patient experiencing severe heartburn at 30 weeks gestation. Eating smaller meals more frequently can help reduce the amount of stomach acid produced, thus decreasing the likelihood of heartburn. Avoiding lying down after meals can prevent stomach acid from flowing back into the esophagus, further reducing heartburn symptoms. Rationale for why other choices are incorrect: A: Lying down after meals can worsen heartburn by allowing stomach acid to flow back into the esophagus. B: Drinking a large amount of water after eating may worsen heartburn by increasing stomach pressure and pushing stomach acid back up. D: Taking antacids regularly may provide temporary relief but is not addressing the root cause of the heartburn and may not be safe for long-term use during pregnancy.
Question 2 of 5
A pregnant patient at 36 weeks gestation reports difficulty breathing when lying flat. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A because positioning the patient in a semi-reclined or left side position can alleviate pressure on the diaphragm and improve breathing. This position helps optimize blood flow to the uterus and placenta. Encouraging rest in this position can improve oxygenation for both the mother and fetus. Administering oxygen (Choice B) may help with oxygenation but does not address the underlying issue of positional discomfort. Monitoring fetal heart rate (Choice C) is important but not the first action to address the mother's breathing difficulty. Instructing the patient to take shallow breaths and stay in bed (Choice D) does not address the positional component of the issue.
Question 3 of 5
A pregnant patient is at 28 weeks gestation and reports occasional headaches and blurred vision. 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. 1. Headaches and blurred vision are common symptoms of preeclampsia. 2. Preeclampsia is a serious condition that can lead to complications for both the mother and baby. 3. Monitoring blood pressure is crucial in diagnosing preeclampsia and determining the appropriate course of action. 4. Prompt assessment and management of preeclampsia are essential to prevent further complications. Incorrect choices: B: Administering pain relief and encouraging rest does not address the underlying cause of the symptoms, which could be preeclampsia. C: Assessing vision and scheduling an appointment with an eye specialist does not address the urgent need to assess for preeclampsia. D: Encouraging fluid intake and avoiding strenuous activity may be helpful in general, but they do not address the potential seriousness of preeclampsia in this
Question 4 of 5
In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
Correct Answer: C
Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.
Question 5 of 5
A nurse is administering an uterotonic medication to a birthing person who has just delivered the placenta. Which uterotonic medication is commonly used to prevent postpartum hemorrhage and promote uterine contractions?
Correct Answer: A
Rationale: The correct answer is A: oxytocin (Pitocin). Oxytocin is commonly used postpartum to prevent hemorrhage and promote uterine contractions due to its ability to stimulate uterine muscle contractions. Oxytocin plays a crucial role in the physiological process of labor and delivery by helping the uterus contract and reduce bleeding. Fentanyl (B), epinephrine (C), and lorazepam (D) are not uterotonic medications and do not have the same effects on the uterus as oxytocin. Fentanyl is an opioid analgesic, epinephrine is a vasoconstrictor, and lorazepam is a sedative, none of which are indicated for preventing postpartum hemorrhage or promoting uterine contractions.