ATI RN
Maternal Monitoring Questions
Question 1 of 5
An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply.
Correct Answer: A
Rationale: In the context of pharmacology, understanding the signs and symptoms of pregnancy is crucial for nurses and healthcare providers involved in maternal monitoring. In this scenario, the correct answer is option A) Amenorrhea, which is a presumptive sign of pregnancy. Amenorrhea refers to the absence of menstrual periods and is one of the earliest signs of pregnancy. It occurs due to the hormonal changes that maintain the uterine lining to support the developing fetus. This sign is considered presumptive because it can also be caused by factors other than pregnancy. Option B) Breast tenderness is a possible sign of pregnancy, but it is not specific to pregnancy as it can also occur due to hormonal fluctuations during the menstrual cycle. Option C) Quickening, which refers to the sensation of fetal movements, is a probable sign of pregnancy and typically occurs later in pregnancy, usually around the second trimester. Option D) Frequent urination is a common symptom in pregnancy due to the increased pressure on the bladder from the growing uterus. It is considered a possible sign but not a presumptive sign of pregnancy. Educationally, it is important for healthcare professionals to differentiate between presumptive, probable, and positive signs of pregnancy to accurately assess and monitor pregnant clients. Understanding these signs helps in providing appropriate care, support, and education to expectant mothers throughout their pregnancy journey.
Question 2 of 5
The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant?
Correct Answer: A
Rationale: In early pregnancy, the presence of a fetal heart rate via Doppler is the most definitive sign that a woman is positively pregnant. This is because the detection of a fetal heartbeat directly confirms the presence of a developing embryo or fetus within the uterus. Option A is correct because it provides direct evidence of the presence of the fetus, making it the most reliable indicator of pregnancy among the options given. Option B, a positive pregnancy test, detects the presence of human chorionic gonadotropin (hCG) hormone in the woman's urine or blood, which indicates pregnancy but does not definitively confirm the presence of a developing fetus. Options C and D, Chadwick's sign and Montgomery gland enlargements, respectively, are physical changes that occur in early pregnancy due to increased blood flow and hormonal changes, but they are not as definitive as detecting a fetal heartbeat. Educationally, understanding the various signs and symptoms of pregnancy is crucial for healthcare professionals, especially nurses, involved in maternal monitoring. This knowledge helps them accurately assess and provide care for pregnant clients, ensuring optimal outcomes for both the mother and the developing fetus.
Question 3 of 5
The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) The nurse midwife felt the baby rebound after being pushed. Ballottement is a technique used in obstetrics to assess fetal movement. When the healthcare provider pushes against the fetus, they feel a rebound movement or a floating back, indicating the fetus is freely movable in the amniotic fluid. This is a positive sign of fetal well-being and growth. Option A) The nurse midwife saw that the mucous plug was intact is incorrect because ballottement is not related to the mucous plug, which is a barrier that seals the cervix. Option C) The nurse midwife palpated the fetal parts through the uterine wall is incorrect because ballottement specifically refers to the rebound of the entire fetus, not just the palpation of fetal parts. Option D) The nurse midwife assessed that the baby is head down is incorrect because ballottement does not provide information about the baby's position in the uterus; it is solely a technique to assess fetal movement. Educationally, understanding terminologies and techniques used in maternal monitoring is crucial for healthcare providers working with pregnant clients. Ballottement is a valuable diagnostic tool that aids in assessing fetal well-being and development. By correctly identifying and interpreting ballottement, healthcare providers can provide accurate information to clients regarding their baby's growth and movement, contributing to effective prenatal care.
Question 4 of 5
A woman in her third trimester advises the nurse that she wishes to breastfeed her baby, 'but I don’t think my nipples are right.' Upon examination, the nurse notes that the client has inverted nipples. Which of the following actions should the nurse take at this time?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take is to refer the client to a lactation consultant for advice (Option B). This is the best course of action because lactation consultants are specifically trained to provide guidance and support for breastfeeding mothers facing challenges, such as inverted nipples. Option A is incorrect because it is not up to the nurse to definitively state that the client will be unable to breastfeed. Breastfeeding is a complex process, and many women with inverted nipples can breastfeed successfully with proper support and techniques. Option C is incorrect as there is no immediate need to notify the labor room about the client's inverted nipples. This issue can be addressed post-delivery with appropriate support. Option D is incorrect because simply teaching exercises to exert the nipples may not be effective or sufficient in addressing the concerns related to inverted nipples when it comes to breastfeeding. In an educational context, it is crucial for nurses to understand the importance of providing evidence-based care and support to breastfeeding mothers. Referring the client to a lactation consultant empowers the mother to receive specialized help and increases the likelihood of successful breastfeeding despite anatomical challenges. Nurses should be knowledgeable about resources available to support breastfeeding mothers and work collaboratively with other healthcare professionals to ensure optimal outcomes for both the mother and baby.
Question 5 of 5
Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client?
Correct Answer: A
Rationale: In pharmacology, understanding maternal monitoring during pregnancy is crucial for nurses to provide optimal care. In this scenario, the correct answer is A) Anemia for a 34-week gestation client. Anemia is a common condition in pregnancy due to an increase in plasma volume that outpaces the increase in red blood cell mass, leading to a dilutional effect. Therefore, it is considered a normal finding in pregnancy, especially in the third trimester. Option B) Thrombocytopenia, a decrease in platelet count, is not a normal finding in pregnancy and can pose risks for bleeding complications during childbirth. Option C) Polycythemia, an elevated red blood cell count, is not expected in a 34-week gestation client and can indicate underlying issues such as dehydration or heart/lung problems. Option D) Hyperbilirubinemia, an increase in bilirubin levels, is not a typical finding in a 34-week gestation client and can be a sign of liver or blood disorders. Educationally, nurses must be able to interpret laboratory reports accurately to provide appropriate care and interventions for pregnant clients. Understanding the normal physiological changes in pregnancy and differentiating them from abnormal findings is essential for ensuring the well-being of both the mother and the fetus.