ATI RN
Maternity Heartbeat Monitor Questions
Question 1 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 2 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 3 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 4 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 5 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.