ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions. A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period. C is incorrect as last food intake and cultural practices are not the most critical assessments during labor. D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
Question 2 of 5
During labor a vaginal examination should be performed only when necessary because of the risk of
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection. Step 2: Infections can be harmful to both the mother and the baby. Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection. Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
Question 3 of 5
The nurse thoroughly dries the infant immediately after birth primarily to
Correct Answer: A
Rationale: The correct answer is A because drying the infant helps reduce heat loss through evaporation, preventing hypothermia. Wet skin can lead to rapid heat loss. This is critical for newborns who are at risk of temperature instability. Choice B is incorrect because drying the infant is not primarily done to stimulate crying and lung expansion. Choice C is incorrect because drying does not increase blood supply to the hands and feet. Choice D is incorrect because maternal blood is typically cleared from the infant's skin through other means, not primarily by drying.
Question 4 of 5
Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Fluid volume deficit (FV) related to fluid loss during labor and birth process. This diagnosis takes priority because dehydration can lead to serious complications for the mother and the baby. Inadequate fluid intake during labor can result in decreased blood volume, affecting both maternal and fetal circulation. This can lead to fetal distress and maternal hypotension. Choice B, fatigue related to length of labor, is important but not as critical as fluid volume deficit, as addressing dehydration is more urgent to prevent complications. Choice C, acute pain related to increased intensity of contractions, is also important but can be managed with pain relief measures, whereas fluid volume deficit requires immediate action. Therefore, it is not the priority at this moment. In summary, addressing fluid volume deficit is the priority as it directly impacts the well-being of both the mother and the baby during labor and birth, while the other options can be addressed once the dehydration issue is resolved.
Question 5 of 5
A nursing priority during admission of a laboring patient who has not had prenatal care is
Correct Answer: B
Rationale: The correct answer is B: identifying labor risk factors. This is a priority because it helps in assessing potential complications and planning appropriate care. Obtaining admission labs (A) can be important but not the top priority. Discussing birth plan choices (C) can wait until after assessing risk factors. Explaining the importance of prenatal care (D) is not the immediate concern during labor admission. Identifying labor risk factors is crucial for ensuring the safety and well-being of both the mother and the baby.