ATI RN
Intrapartum Complications NCLEX Questions Questions
Question 1 of 5
Decelerations that mirror the contractions are present with each contraction on the monitor strip of a multipara who received epidural anesthesia 20 minutes ago. The nurse should
Correct Answer: A
Rationale: The correct answer is A: maintain the normal assessment routine. Decelerations mirroring contractions in a multipara with epidural anesthesia likely indicate normal physiologic response to labor. There is no indication of fetal distress. Administering O2 (B) is unnecessary as there is no indication of maternal hypoxemia. Increasing IV flow rate (C) is not necessary if there are no signs of hypovolemia. Assessing maternal blood pressure (D) for hypotension is not relevant without other signs of maternal compromise. Maintaining the normal assessment routine ensures ongoing monitoring and evaluation of both mother and baby without unnecessary interventions.
Question 2 of 5
When evaluating the patient's progress, the nurse knows that four of the five fetal factors that interact to regulate the heart Nrate Rare I(SeGlect Bal.l CthatM apply.) U S N T O
Correct Answer: A
Rationale: The correct answer is A: baroreceptors. Baroreceptors are sensory receptors that detect changes in blood pressure and play a role in regulating heart rate. They are one of the fetal factors that interact to regulate heart rate. Adrenal glands (B) primarily regulate stress response, chemoreceptors (C) detect changes in oxygen and carbon dioxide levels, and uterine activity (D) refers to contractions during labor, which are not directly related to regulating fetal heart rate. Thus, A is correct as it directly influences heart rate regulation.
Question 3 of 5
When assessing a prenatal client at follow-up prenatal visits during the second trimester, the nurse should anticipate which assessments to be performed at each visit? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Weight, height, BMI. During each second-trimester prenatal visit, it is essential to monitor the client's weight, height, and BMI to ensure appropriate maternal and fetal health. Weight gain is a crucial indicator of fetal growth and maternal well-being. Height and BMI can provide insights into the client's nutritional status and overall health. Explanation of why other choices are incorrect: A: Cervical examination is typically not performed routinely during second-trimester prenatal visits unless there are specific concerns such as preterm labor risk. C: Fetal ultrasound is usually scheduled at specific times during pregnancy, not necessarily at every second-trimester visit. D: Fundal height measurement is important, but it is usually performed starting in the second trimester to assess fetal growth and position, not necessarily at every visit.
Question 4 of 5
Which statement by the patient indicates to the nurse that the patient understands danger signs during the second trimester?
Correct Answer: C
Rationale: The correct answer is C because pain while urinating can be a sign of a urinary tract infection, which is common during pregnancy and can lead to complications if not treated promptly. Heartburn, constipation, and leg cramps are common discomforts during pregnancy but are not typically considered emergency danger signs. Therefore, option C is the most critical symptom that requires immediate medical attention to prevent potential harm to the mother and baby.
Question 5 of 5
The nurse is assessing the client for the presence of ballottement. Which should the nurse perform to test for the presence of ballottement?
Correct Answer: C
Rationale: The correct answer is C. To test for the presence of ballottement, the nurse should initiate a gentle upward tap on the cervix. Ballottement is a technique used in obstetrics to assess for the presence of a floating object in the uterus, such as a fetus. By tapping the cervix gently, the nurse can feel for a rebound effect, indicating the presence of a floating object. This technique helps to confirm the presence of a fetus in the uterus. Explanation of why other choices are incorrect: A: Palpating the uterus for contractions is not relevant to testing for ballottement. B: Assessing the skin for increased pigmentation is not related to assessing for the presence of a floating object in the uterus. D: Palpating the abdomen for fetal outline does not specifically test for ballottement, which involves tapping the cervix.