ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 4
At 6 weeks gestation the rubella titer of a client medication indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?
Correct Answer: D
Rationale: The correct answer is D) Early postpartum within 72 hours of delivery. Administering the rubella vaccine early postpartum is crucial as it ensures protection for the mother before she conceives her next child. By vaccinating the mother in the early postpartum period, it helps prevent congenital rubella syndrome in future pregnancies. Option A) After the client stops breastfeeding is incorrect because delaying the vaccine until the client stops breastfeeding leaves her vulnerable to rubella infection during that period, potentially affecting future pregnancies. Option B) Immediately, at 6-weeks gestation to protect the fetus is incorrect because administering live vaccines during pregnancy is contraindicated due to the theoretical risk of harm to the fetus. Option C) After the client reaches 20-weeks gestation is incorrect because waiting until 20 weeks gestation may not provide adequate protection to the mother during the vulnerable period between pregnancies. Educationally, understanding the timing of rubella vaccination in the postpartum period is essential for healthcare providers working in maternity care to ensure optimal maternal and fetal health outcomes. It highlights the importance of proper timing in administering vaccines to protect both the mother and future pregnancies.
Question 2 of 4
A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client?
Correct Answer: C
Rationale: The correct answer is option C: "When there is no significant vaginal bleeding." This is the most important information for the nurse to provide the client because it indicates the status of the client's postpartum bleeding, which is a crucial aspect to monitor following delivery. Significant vaginal bleeding could be a sign of postpartum hemorrhage, a serious complication that requires immediate medical attention to prevent further complications or harm to the mother. Option A, "When ambulating to void does not cause dizziness," while important for the client's safety, is not as critical as monitoring for postpartum bleeding. Option B, "After the vitamin K injection is given to the baby," and Option D, "After the baby no longer demonstrates acrocyanosis," are related to the newborn's care and not directly relevant to the client's discharge readiness. In an educational context, this question emphasizes the importance of prioritizing postpartum assessment and teaching in maternity care. Nurses need to educate clients on postpartum warning signs, including excessive bleeding, to ensure optimal postpartum recovery and prevent complications. This scenario highlights the nurse's role in providing essential information to empower clients to make informed decisions about their health and well-being during the postpartum period.
Question 3 of 4
At 0600 while admitting a woman for a scheduled repeat Caesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take first is to inform the anesthesia care provider (Option C). The client drinking coffee close to the scheduled C-section time is crucial information because caffeine can affect anesthesia. Anesthesia providers need to be aware of any substance consumption that can impact the anesthesia plan to ensure the client's safety during the procedure. Option A (Contact the client's obstetrician) is incorrect because the immediate concern is the impact of caffeine on anesthesia, which falls under the anesthesia provider's purview. Option B (Ensure preoperative lab results are available) is not the priority as the client's recent caffeine intake poses a more urgent issue. Option D (Start prescribed IV with Lactated Ringer's) is not the best initial action as addressing the caffeine intake's potential impact on anesthesia takes precedence. Educationally, this scenario highlights the importance of thorough preoperative assessments and the need to communicate pertinent information promptly to the appropriate members of the healthcare team. It also emphasizes the critical role nurses play in advocating for patient safety by ensuring all relevant details are shared with the anesthesia team for optimal patient outcomes.
Question 4 of 4
A client at 20 weeks gestation comes to antepartum clinic complaining of vaginal warts (human papilloma virus HPV). What information should the nurse provide this client?
Correct Answer: B
Rationale: In this scenario, option B is the correct answer. The nurse should inform the client that pregnancy complications are not directly linked to HPV. It is important for the nurse to provide accurate and evidence-based information to the client. HPV, the virus that causes genital warts, does not typically lead to pregnancy complications. It is essential for the nurse to reassure the client and alleviate any concerns regarding the impact of HPV on her pregnancy. Option A is incorrect because termination of the pregnancy is not indicated solely based on the presence of HPV. Option C is incorrect because acyclovir (Zovirax) is used to treat herpes simplex virus (HSV) infections, not HPV. Option D is incorrect because penicillin G is an antibiotic used to treat bacterial infections, not viral infections like HPV. Educationally, this question highlights the importance of providing accurate and non-alarming information to pregnant clients. Nurses play a crucial role in educating clients about their health conditions and dispelling any myths or misconceptions. It is essential for healthcare providers to offer evidence-based information to empower clients to make informed decisions about their health and pregnancy.