ATI RN
Maternity Heartbeat Monitor Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A nurse is caring for a pregnant patient at 34 weeks gestation who has been diagnosed with gestational hypertension. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient's blood pressure regularly and assess for signs of preeclampsia. At 34 weeks gestation with gestational hypertension, monitoring blood pressure and assessing for signs of preeclampsia are crucial to detect any worsening condition. Preeclampsia is a serious complication of gestational hypertension that can lead to adverse outcomes for both the mother and fetus. Regular monitoring allows for timely intervention if necessary. Choice A is incorrect because simply encouraging rest and increased fluid intake may not address the potential severity of gestational hypertension and preeclampsia. Choice C is incorrect because administering antihypertensive medications without proper monitoring and assessment can be harmful to the patient and fetus. Choice D is incorrect because lying on her back can actually worsen the patient's condition by decreasing blood flow to the uterus.
Question 5 of 5
A pregnant patient at 36 weeks gestation is experiencing swelling in her hands and feet. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A. At 36 weeks gestation, swelling in the hands and feet could be a sign of preeclampsia, a serious condition. The nurse's priority is to monitor the patient's blood pressure and assess for other signs of preeclampsia, such as headache, visual disturbances, and proteinuria. Prompt detection and management of preeclampsia are crucial to prevent complications like eclampsia and HELLP syndrome. Choices B, C, and D do not address the potential seriousness of the situation and may delay the necessary assessment and intervention for preeclampsia.