ATI RN
Adult Health Nursing Test Bank Questions
Question 1 of 5
A pregnant woman presents with fever, chills, and abdominal pain localized to the right upper quadrant. On examination, she has tenderness in the right upper abdomen and a positive Murphy's sign. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: C
Rationale: The scenario described in the question is consistent with acute cholecystitis, which is inflammation of the gallbladder usually caused by an impacted gallstone in the cystic duct. The key clinical features of acute cholecystitis include fever, chills, right upper quadrant abdominal pain (which can be localized to the right upper quadrant), tenderness in the right upper abdomen, and a positive Murphy's sign (pain and inspiratory arrest upon palpation of the right upper quadrant). This condition is more common in pregnant women due to hormonal changes that can lead to gallstone formation and subsequent inflammation of the gallbladder. Ectopic pregnancy, pelvic inflammatory disease, and ovarian torsion typically present with different clinical features compared to those described in acute cholecystitis.
Question 2 of 5
A woman in active labor is experiencing precipitous labor with rapid cervical dilation and descent of the fetal presenting part. What maternal complication should the nurse anticipate?
Correct Answer: A
Rationale: Precipitous labor is characterized by rapid cervical dilation and descent of the fetal presenting part, leading to a shortened labor duration of less than 3 hours. This rapid progression can increase the risk of maternal complications, such as postpartum hemorrhage. Postpartum hemorrhage is defined as excessive bleeding of more than 500 ml after vaginal delivery or more than 1000 ml after cesarean delivery. The rapid delivery in precipitous labor can result in inadequate uterine contractions after delivery, leading to poor uterine tone and potential postpartum hemorrhage due to uterine atony. Therefore, the nurse should anticipate postpartum hemorrhage as a potential maternal complication in a woman experiencing precipitous labor.
Question 3 of 5
During the active phase of labor, a woman's cervical dilation is progressing slowly despite regular contractions. What maternal condition should the nurse assess for that may contribute to abnormal labor progression?
Correct Answer: B
Rationale: One potential maternal condition that may contribute to abnormal labor progression with slow cervical dilation despite regular contractions is pelvic outlet obstruction. This can occur if the maternal pelvis is too small, misshapen, or has an obstruction such as a fibroid tumor. The inadequate space in the pelvis can prevent the fetus from descending properly and can result in a prolonged or difficult labor. If suspected, interventions such as a cesarean delivery may be necessary to prevent complications for both the mother and baby. It is essential for the nurse to assess for signs of pelvic outlet obstruction and work with the healthcare team to address any issues promptly to ensure a safe delivery.
Question 4 of 5
A woman in active labor demonstrates signs of uterine inertia, with weak and irregular contractions contributing to slow cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
Correct Answer: A
Rationale: In cases of uterine inertia, where weak and irregular contractions are causing slow cervical dilation during labor, administering intravenous oxytocin can help augment contractions and stimulate more effective progress. Oxytocin is a hormone that naturally stimulates uterine contractions and is commonly used in clinical settings to induce or enhance labor. By increasing the strength and frequency of contractions, oxytocin can help address uterine inertia and promote efficient cervical dilation to facilitate the progress of labor. It is important to monitor the response to oxytocin carefully to avoid complications such as hyperstimulation of the uterus, which can lead to fetal distress.
Question 5 of 5
A woman in active labor demonstrates signs of prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
Correct Answer: B
Rationale: When a woman in active labor exhibits signs of prolonged second stage, such as ineffective pushing efforts and slow fetal descent, one of the maternal conditions that should be considered is pelvic floor dysfunction. The pelvic floor muscles play a crucial role in supporting the uterus, bladder, and rectum. If these muscles are weak or dysfunctional, it can lead to difficulty in pushing effectively and impede the descent of the fetus through the birth canal. This can result in prolonged labor and increase the risk of complications for both the mother and the baby. Therefore, assessing for pelvic floor dysfunction is important in addressing the abnormal labor pattern and providing appropriate interventions to support the progress of labor.