ATI RN
Maternity Heartbeat Monitor Questions
Question 1 of 5
A pregnant patient is 36 weeks gestation and reports increased vaginal discharge. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Assess the nature of the discharge for signs of infection. At 36 weeks gestation, increased vaginal discharge could be a sign of infection, such as bacterial vaginosis or yeast infection, which can lead to preterm labor. The nurse's priority is to assess for infection to prevent any potential harm to the mother and baby. By assessing the nature of the discharge, the nurse can determine if further evaluation or treatment is needed. Choice B is incorrect because instructing the patient to monitor the discharge at home does not address the potential seriousness of the situation. Choice C is incorrect as using panty liners only manages the symptom without addressing the underlying cause. Choice D is incorrect because providing education about normal pregnancy changes does not address the immediate need to rule out infection in this scenario.
Question 2 of 5
The nurse is caring for a pregnant patient who is 22 weeks gestation and has a history of gestational hypertension. What should the nurse monitor most closely?
Correct Answer: B
Rationale: The correct answer is B: Protein in the urine to assess for preeclampsia. The nurse should closely monitor protein in the urine because the patient has a history of gestational hypertension, which puts her at risk for developing preeclampsia. Preeclampsia is characterized by high blood pressure and proteinuria. Monitoring protein in the urine helps detect early signs of preeclampsia, which can lead to serious complications for both the mother and the fetus if left untreated. Blood glucose levels (A) are not the priority in this case, as the patient's history indicates a higher risk for preeclampsia. Fetal heart rate (C) and daily weight gain (D) are important aspects to monitor during pregnancy; however, in this scenario, the focus should be on detecting signs of preeclampsia due to the patient's history of gestational hypertension.
Question 3 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 4 of 5
A pregnant patient is at 24 weeks gestation and reports pain in her lower abdomen and back. What is the nurse's first priority action?
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdomen and back pain could be indicative of preterm labor. Therefore, the nurse's first priority should be to assess the patient for signs of preterm labor, such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. This is crucial to determine if the patient and the fetus are in any immediate danger. Administering pain medication (choice A), instructing relaxation techniques (choice C), or encouraging exercise (choice D) are not appropriate initial actions as they do not address the potential serious issue of preterm labor.
Question 5 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.