ATI RN
Maternal Diseases During Pregnancy Questions
Question 1 of 5
Choose the appropriate infant care teaching for a woman who has given birth by cesarean because of active genital herpes.
Correct Answer: B
Rationale: The correct answer is B) Thoroughly wash your hands before handling the infant. This is the appropriate infant care teaching for a woman who has given birth by cesarean due to active genital herpes because hand hygiene is crucial in preventing the transmission of the herpes virus to the newborn. Option A) Do not breastfeed the infant until all lesions are healed is incorrect because breastfeeding is still possible with proper precautions, such as ensuring good hand hygiene. Option C) Wear a mask when breastfeeding or holding the infant close is not necessary as long as proper handwashing is practiced. Option D) No special precautions are needed when caring for the infant is incorrect as precautions should be taken to prevent the spread of the herpes virus to the newborn. In an educational context, it is important to emphasize the significance of hand hygiene in preventing the transmission of infectious diseases from mother to infant, especially in cases where the mother has an active infection like genital herpes. Teaching proper handwashing techniques and emphasizing its importance can help protect the infant from potential harm.
Question 2 of 5
The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding?
Correct Answer: A
Rationale: In the context of mild preeclampsia, bed rest is often recommended to manage the condition and reduce the risk of complications. Weight loss would be considered a positive finding when evaluating the effectiveness of bed rest because it may indicate a reduction in edema, which is a common symptom of preeclampsia. Weight loss can also suggest a decrease in fluid retention and potentially improved circulation, which are beneficial in managing preeclampsia. Option B, 2+ proteinuria, is an indicator of renal involvement in preeclampsia and would not be considered a positive finding when evaluating the effectiveness of bed rest. It suggests ongoing kidney damage and the progression of the disease. Option C, decrease in plasma protein, is not a typical parameter used to evaluate the effectiveness of bed rest in managing mild preeclampsia. While preeclampsia can affect plasma proteins, it is not a direct measure of the response to bed rest. Option D, 3+ patellar reflexes, is not relevant to assessing the effectiveness of bed rest for preeclampsia. Increased deep tendon reflexes may indicate conditions like hyperthyroidism or neurological issues but are not specific to preeclampsia management. In an educational context, understanding the rationale behind monitoring specific signs and symptoms in preeclampsia is crucial for nurses caring for pregnant women. Recognizing positive and negative findings helps nurses make informed decisions about patient care and treatment interventions.
Question 3 of 5
A nurse remarks to a 38-week-gravid client, 'It looks like your face and hands are swollen.' The client responds, 'Yes, you're right. Why do you ask?' The nurse's response is based on the fact that the changes may be caused by which of the following?
Correct Answer: A
Rationale: The correct answer is A) Altered glomerular filtration. During pregnancy, there is an increase in blood volume and pressure, leading to altered kidney function. This alteration in glomerular filtration causes retention of sodium and water, resulting in edema or swelling, particularly in the face and hands. Option B) Cardiac failure is incorrect because swelling in the face and hands during pregnancy is not typically associated with cardiac issues unless there are pre-existing heart conditions. Option C) Hepatic insufficiency is incorrect as liver dysfunction does not directly cause swelling in the face and hands during pregnancy. Liver-related issues may manifest as jaundice or other symptoms. Option D) Altered splenic circulation is also incorrect because spleen-related problems do not usually result in swelling in the face and hands during pregnancy. Educationally, understanding the physiological changes during pregnancy is crucial for healthcare providers to recognize and address common issues like edema. By knowing the impact of altered glomerular filtration, nurses can provide appropriate care and education to pregnant clients to ensure optimal maternal and fetal health.
Question 4 of 5
A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform?
Correct Answer: C
Rationale: In the assessment of clonus in a client with severe preeclampsia, the correct action for the nurse to perform is to dorsiflex the woman's foot (Option C). Clonus is characterized by repetitive, rhythmic contractions and relaxations of a muscle. By dorsiflexing the foot, the nurse can elicit this response in the client, which is indicative of neurological hyperactivity associated with conditions like preeclampsia. Option A, striking the woman's patellar tendon, is incorrect as this action tests for deep tendon reflexes, not clonus. Palpating the woman's ankle (Option B) does not elicit a response related to clonus. Positioning the woman's feet flat on the floor (Option D) is also not directly related to assessing clonus. Educationally, understanding the specific assessment techniques for conditions like preeclampsia is crucial for nurses caring for pregnant clients. Proper assessment skills can help in early detection of complications, leading to timely interventions and improved outcomes for both the mother and the baby. Practicing and mastering these assessment techniques is vital for providing safe and effective care in maternal health settings.
Question 5 of 5
A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B) Papilledema. Papilledema is a classic sign of severe preeclampsia, indicating increased intracranial pressure due to cerebral edema. This condition can lead to visual disturbances and is a critical indicator of worsening preeclampsia that requires immediate intervention to prevent seizures and other serious complications. Option A) Fundal height of 32 cm is not directly related to the presentation of severe preeclampsia. Fundal height is typically used to assess fetal growth and gestational age. Option C) Patellar reflexes of +2 are a normal finding and not specific to the clinical manifestations of severe preeclampsia. Option D) Nystagmus is not a typical sign of severe preeclampsia and is more commonly associated with neurological or vestibular disorders. Educationally, understanding the signs and symptoms of severe preeclampsia is crucial for healthcare providers caring for pregnant women. Recognizing these signs promptly can help prevent maternal and fetal complications. Regular monitoring and assessment are essential components of prenatal care to detect and manage conditions like severe preeclampsia effectively.