ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?
Correct Answer: D
Rationale: The correct answer is D. Edema and discoloration of the labia and perineum indicate the presence of a potential vaginal wall hematoma. This is because hematoma can cause swelling and bruising in the affected area. Bright red lochia and a firm fundus are more indicative of postpartum hemorrhage, not vaginal wall hematoma. Choices A and C are not directly related to the presence of a vaginal wall hematoma. Mild, intermittent perineal pain (Choice B) is non-specific and can be present in various postpartum conditions. Thus, option D is the most relevant indicator of a potential vaginal wall hematoma in this scenario.
Question 2 of 5
Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
Correct Answer: A
Rationale: The correct action is to assess the infant for signs of trauma (Choice A) because forceps-assisted birth can increase the risk of injury to the infant. By assessing for signs of trauma promptly, the nurse can identify any potential issues and initiate necessary interventions. Choice B is incorrect because measuring the circumference of the infant's head is not necessary immediately after forceps-assisted birth. Choice C is incorrect as applying a cold pack to the infant's scalp is not indicated unless there is a specific medical reason for it. Choice D is incorrect because giving prophylactic antibiotics to the infant is not a standard practice following forceps-assisted birth unless there is a specific indication for infection prevention.
Question 3 of 5
The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?
Correct Answer: D
Rationale: The correct answer is D because a patient with previous surgery in the upper uterus is at risk for uterine rupture with prostaglandin use. Previous surgery in the upper uterus may weaken the uterine wall, increasing the risk of complications such as uterine rupture during cervical ripening. A: Bishop's score of 5 indicates a moderate readiness for induction, making vaginal prostaglandin appropriate. B: 42 weeks of gestation is considered post-term, where cervical ripening is often needed. C: Previous low transverse cesarean birth is not a contraindication for prostaglandin use for cervical ripening.
Question 4 of 5
Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?
Correct Answer: B
Rationale: The correct answer is B: Symmetry of facial movements. Bruising over the cheeks can indicate potential nerve damage from the forceps birth. Assessing facial movements helps determine if there is any nerve injury affecting facial muscles. Presence of newborn reflexes (A) is important but not directly related to facial nerve injury. Caput and molding of the head (C) are more related to the birthing process and not specific to facial nerve assessment. Anterior and posterior fontanels (D) are important for assessing fontanelle closure but not specific to facial nerve evaluation.
Question 5 of 5
Following an external cephalic version, which assessment finding indicates a complication?
Correct Answer: C
Rationale: The correct answer is C: Deceleration of FHR to 88 bpm. This finding indicates fetal distress, a complication post external cephalic version. Deceleration of FHR suggests reduced oxygenation to the fetus. A: Onset of irregular contractions is a common post-procedure finding and not necessarily indicative of a complication. B: Maternal blood pressure of 110/70 mm Hg is within normal range and not directly related to a complication. D: Maternal pulse rate of 100 bpm is slightly elevated but not a specific indicator of a complication post external cephalic version.