ATI RN
Adult Health Nursing Test Bank Questions
Question 1 of 5
A woman in active labor is receiving an epidural analgesic for pain relief. What assessment findings indicate a potential complication of epidural analgesia?
Correct Answer: A
Rationale: One potential complication of epidural analgesia in labor is maternal hypotension. The epidural analgesic can cause vasodilation, leading to a decrease in blood pressure. Maternal hypotension can result in decreased placental perfusion, which may jeopardize fetal well-being. It is important for healthcare providers to monitor the maternal blood pressure closely and intervene promptly if hypotension occurs by providing IV fluids or administering medication to raise blood pressure. Uterine hyperstimulation, fetal tachycardia, and respiratory depression are not typically associated with epidural analgesia as complications.
Question 2 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 3 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 4 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.
Question 5 of 5
A postpartum client who delivered via cesarean section expresses discomfort when ambulating and performing activities of daily living. What nursing intervention should be prioritized to promote optimal recovery?
Correct Answer: A
Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.