ATI RN
Maternal Monitoring During Labor Questions
Question 1 of 5
A pregnant patient at 34 weeks gestation reports sudden swelling of the 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. Rationale: 1. Sudden swelling of the hands, feet, and face in a pregnant patient at 34 weeks gestation can be a sign of preeclampsia. 2. Preeclampsia is a serious condition characterized by high blood pressure and protein in the urine, which can lead to complications for both the mother and the baby. 3. Monitoring the patient's blood pressure and checking for signs of preeclampsia is crucial for early detection and management of the condition. 4. Prompt intervention is necessary to prevent potential severe outcomes such as seizures, stroke, or organ damage. Summary of Incorrect Choices: B: Elevating the legs may provide temporary relief but does not address the underlying cause of the sudden swelling, which could be preeclampsia. C: Administering diuretics without assessing the patient's blood pressure and ruling out
Question 2 of 5
The nurse is caring for a pregnant patient who is at 36 weeks gestation and reports severe lower back pain. What should the nurse recommend?
Correct Answer: B
Rationale: The correct answer is B because engaging in light physical activity and maintaining good posture can help alleviate lower back pain during pregnancy by strengthening muscles and improving circulation. Resting may worsen the pain. Applying heat or cold packs may provide temporary relief but does not address the underlying issue. Lying flat on her back for extended periods can lead to decreased blood flow to the uterus and potentially harm the baby.
Question 3 of 5
A pregnant patient is at 32 weeks gestation and reports swelling of the feet and legs. What is the most appropriate recommendation for the nurse to make?
Correct Answer: B
Rationale: The correct answer is B. Elevating the legs and avoiding prolonged standing is the most appropriate recommendation for a pregnant patient experiencing swelling at 32 weeks gestation. Elevating the legs helps to reduce swelling by aiding in venous return and reducing fluid accumulation in the lower extremities. Prolonged standing can worsen swelling due to increased pressure on the veins. Limiting fluid intake (choice A) may lead to dehydration and is not recommended during pregnancy. Applying compression stockings (choice C) may help improve circulation but may not address the underlying cause of swelling. Resting in bed with feet elevated at all times (choice D) is excessive and may not be practical for the patient.
Question 4 of 5
A nurse is caring for a pregnant patient who is at 24 weeks gestation and reports feeling fatigued and weak. What is the most appropriate action for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's hemoglobin levels to check for anemia. Fatigue and weakness are common symptoms of anemia, especially in pregnant women. By assessing the hemoglobin levels, the nurse can determine if the patient is anemic and needs appropriate treatment. This step is crucial for identifying and addressing the underlying cause of the symptoms. Summary: B: Recommending a high-calorie diet may not address the root cause of the fatigue and weakness, which could be anemia. C: While rest is important during pregnancy, simply encouraging rest without investigating the cause of the symptoms may delay appropriate treatment. D: While gentle exercises can be beneficial during pregnancy, they may not be suitable if the patient is experiencing significant fatigue and weakness due to anemia.
Question 5 of 5
A pregnant patient at 28 weeks gestation reports lower back pain. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B because assessing the patient's posture and recommending appropriate exercises can help alleviate lower back pain during pregnancy. Poor posture and lack of exercise are common causes of back pain in pregnancy. Administering pain medication as in choice A may not address the root cause. Instructing the patient to lie flat on her back (choice C) can actually worsen back pain and pose risks during pregnancy. Performing a pelvic exam (choice D) is not necessary unless there are specific indications for it related to the patient's complaint. Therefore, choice B is the most appropriate initial action to address the lower back pain in this pregnant patient.