ATI RN
Maternal Monitoring During Labor Questions
Question 1 of 5
A pregnant patient is at 32 weeks gestation and reports a sudden headache and visual disturbances. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B because sudden headache and visual disturbances in a pregnant patient at 32 weeks gestation could indicate preeclampsia. Assessing blood pressure and checking for protein in the urine are crucial steps in diagnosing preeclampsia, a serious condition that requires immediate medical attention to prevent complications for both the mother and baby. Encouraging rest, administering pain medication, or suggesting caffeinated beverages may mask symptoms but not address the underlying issue of preeclampsia. Therefore, prompt assessment and monitoring of blood pressure and urine protein levels are essential in this scenario.
Question 2 of 5
A pregnant patient who is 28 weeks gestation reports a sudden headache and visual changes. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B. Assess the patient's blood pressure and check for signs of preeclampsia. This is the priority action because sudden headache and visual changes in a pregnant patient at 28 weeks gestation could indicate preeclampsia, a serious condition characterized by high blood pressure and organ damage. Checking blood pressure and signs of preeclampsia is crucial for early detection and prompt management to prevent complications for both the mother and baby. Encouraging a warm bath, administering pain medication, or instructing the patient to rest may provide temporary relief but do not address the underlying cause of the symptoms.
Question 3 of 5
The nurse is caring for a pregnant patient who is 24 weeks gestation and has been diagnosed with a urinary tract infection (UTI). Which of the following interventions should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics as prescribed. The priority is to treat the UTI to prevent potential harm to the patient and fetus. Antibiotics are necessary to eliminate the infection and reduce the risk of complications. Encouraging cranberry juice (B) may be beneficial for prevention but is not sufficient to treat an existing UTI. Providing education about preterm labor signs (C) is important but addressing the infection is the immediate concern. Scheduling a follow-up ultrasound (D) may be necessary later but does not address the urgent need to treat the UTI.
Question 4 of 5
A pregnant patient at 24 weeks gestation reports experiencing leg cramps. What is the most appropriate intervention for the nurse to recommend?
Correct Answer: C
Rationale: The correct answer is C: Elevate the legs and perform gentle stretching exercises. Leg cramps during pregnancy are common due to increased weight and pressure on the legs. Elevating the legs helps improve circulation and reduce cramping. Gentle stretching exercises can also help relieve muscle tension. Increasing calcium intake (choice A) may be beneficial for preventing cramps, but it is not the immediate intervention for relief. Exercise (choice B) may worsen cramping if done excessively. Applying heat packs (choice D) may provide temporary relief but does not address the underlying cause of the cramps.
Question 5 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