ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
A woman who delivered a 9-pound baby boy by cesarean section under spinal anesthesia is recovering in the post anesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina is observed by the nurse. Which actions should the nurse implemented.
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take is to assess the woman's blood pressure (Option B). This is because the woman delivered a large baby via cesarean section, which puts her at higher risk for postpartum hemorrhage. The presence of bright red blood with no clots indicates active bleeding, and assessing her blood pressure can help determine if she is experiencing hypovolemic shock, a serious complication of postpartum hemorrhage. Prompt assessment and intervention are crucial in preventing further complications. Massage the fundus (Option A) is generally done to help the uterus contract and prevent excessive bleeding, but in this case, the fundus is already firm at the umbilicus, so massaging it may not be necessary and could even potentially cause discomfort. Applying an ice pack to the perineum (Option C) is commonly done for perineal pain and swelling after vaginal delivery, but it is not the priority in this situation where the focus should be on assessing and managing postpartum hemorrhage. Letting the infant breastfeed (Option D) is important for bonding and initiating breastfeeding, but it is not the most urgent action to take in this situation where the priority is to assess and manage potential postpartum hemorrhage. Educationally, this scenario highlights the importance of recognizing signs of postpartum hemorrhage and the need for prompt assessment and intervention in such situations to ensure the well-being of the mother. It emphasizes the significance of prioritizing actions based on the patient's condition and potential complications.
Question 2 of 5
A client at 38-weeks gestation complaints of severe abdominal pain. Upon the nurse notes that the abdomen is rigid.
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Abruptio placenta. This condition involves the premature separation of the placenta from the uterine wall before delivery, leading to severe abdominal pain and a rigid abdomen due to internal bleeding and clot formation behind the placenta. Option A) Placenta previa is characterized by painless vaginal bleeding in the third trimester, not severe abdominal pain and rigidity. Option B) Oligohydramnios refers to low levels of amniotic fluid and is not typically associated with severe abdominal pain or rigidity. Option D) Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, presenting with fever, uterine tenderness, and foul-smelling amniotic fluid, rather than severe abdominal pain and rigidity. Educationally, understanding these differential diagnoses is crucial for nursing students or healthcare providers working in maternity care to accurately assess and manage pregnant clients experiencing abdominal pain. Recognizing the signs and symptoms of abruptio placenta is vital for prompt intervention to ensure the well-being of both the mother and the fetus.
Question 3 of 5
The nurse is performing a newborn assessment. Which symptoms if present in newborn, would indicate respiratory distress?
Correct Answer: C
Rationale: In newborn assessment, recognizing signs of respiratory distress is crucial for prompt intervention. Option C, "Flaring of the nares," is the correct answer indicating respiratory distress in a newborn. Nasal flaring is a common sign of increased work of breathing and inadequate oxygenation. It suggests the baby is struggling to get enough oxygen. Option A, "Abdominal breathing with synchronous chest movement," is incorrect as it describes a normal breathing pattern in newborns due to their immature respiratory system. Option B, "Shallow and irregular respirations," while abnormal, do not specifically indicate respiratory distress. Option D, "Respiratory rate of 50 breaths per minute," is within the normal range for a newborn. It is important to educate nurses that isolated respiratory rate alone may not always indicate distress; it must be interpreted in conjunction with other signs like nasal flaring, grunting, retracting, or cyanosis. Educationally, understanding these signs equips nurses to identify respiratory distress early, intervene promptly, and prevent potential complications in newborns. It is crucial for nurses working in maternity settings to be adept at recognizing these signs to ensure the well-being of neonates.
Question 4 of 5
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 stations. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first.
Correct Answer: D
Rationale: In this scenario, the most appropriate action for the nurse to implement first is to determine cervical dilation (Option D). This is crucial because the client was admitted in active labor, and any changes in the cervix dilation can indicate progress or abnormalities in the labor process. Monitoring the cervical dilation helps the nurse assess the stage of labor and make informed decisions regarding the client's care and potential interventions. Checking the pH of the vaginal fluid (Option A) is not the priority in this situation as it does not provide immediate information related to the client's current labor progress. Reviewing the fetal heart rate pattern (Option B) is essential but should come after assessing the cervix to ensure the progress of labor. Palpating the client's bladder (Option C) is important for assessing bladder fullness but is not as urgent as determining cervical dilation in this active labor situation. Educationally, understanding the significance of assessing cervical dilation in active labor is essential for nurses and healthcare providers involved in maternity care. It helps them make timely decisions, monitor labor progress, and provide appropriate care to ensure a safe delivery for the mother and baby. This rationale highlights the importance of prioritizing tasks based on the client's condition and the stage of labor.
Question 5 of 5
Which content should the nurse plan to include in a nutrition class for pregnant adolescents? (Select ONE that does not apply)
Correct Answer: B
Rationale: In planning a nutrition class for pregnant adolescents, it is crucial to provide accurate and evidence-based information to support their health and the health of their developing babies. The correct answer, option B, "Gain no more than 15 pounds during the pregnancy," is important because excessive weight gain during pregnancy can lead to various complications such as gestational diabetes, high blood pressure, and increased risk of cesarean delivery. Option A, "Take iron and calcium supplements daily," is essential during pregnancy to support the increased demands for these nutrients, especially since many pregnant women struggle to meet their needs through diet alone. Option C, "Increase food intake by 300 to 400 calories/day," is also crucial as pregnant adolescents need more calories to support the growth and development of the fetus. Option D, "Take folic acid supplement daily," is critical for preventing neural tube defects in the developing baby. While all the options are important components of a healthy pregnancy, the correct answer focuses on the specific issue of weight gain, which is often a concern for adolescents who may already be conscious of body image. Educationally, emphasizing the importance of balanced weight gain during pregnancy can help adolescents make informed choices to support a healthy pregnancy and delivery. It is essential to provide guidance and support to ensure that pregnant adolescents receive accurate information and appropriate care throughout their pregnancy journey.