ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
During labor a vaginal examination should be performed only when necessary because of the risk of
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection. Step 2: Infections can be harmful to both the mother and the baby. Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection. Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
Question 2 of 5
Which nursing diagnosis would take priority in the care of a primipara patient with no visible support person in attendance? The patient has entered the second stage of labor after a first stage of labor lasting 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Fluid volume deficit (FV) related to fluid loss during labor and birth process. This diagnosis takes priority because dehydration can lead to serious complications for the mother and the baby. Inadequate fluid intake during labor can result in decreased blood volume, affecting both maternal and fetal circulation. This can lead to fetal distress and maternal hypotension. Choice B, fatigue related to length of labor, is important but not as critical as fluid volume deficit, as addressing dehydration is more urgent to prevent complications. Choice C, acute pain related to increased intensity of contractions, is also important but can be managed with pain relief measures, whereas fluid volume deficit requires immediate action. Therefore, it is not the priority at this moment. In summary, addressing fluid volume deficit is the priority as it directly impacts the well-being of both the mother and the baby during labor and birth, while the other options can be addressed once the dehydration issue is resolved.
Question 3 of 5
A nursing priority during admission of a laboring patient who has not had prenatal care is
Correct Answer: B
Rationale: The correct answer is B: identifying labor risk factors. This is a priority because it helps in assessing potential complications and planning appropriate care. Obtaining admission labs (A) can be important but not the top priority. Discussing birth plan choices (C) can wait until after assessing risk factors. Explaining the importance of prenatal care (D) is not the immediate concern during labor admission. Identifying labor risk factors is crucial for ensuring the safety and well-being of both the mother and the baby.
Question 4 of 5
The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?
Correct Answer: B
Rationale: The correct answer is B: 20-gauge. During active labor, a larger IV cannula is recommended to accommodate rapid fluid administration and potential blood loss. A 20-gauge cannula provides a good balance between flow rate and patient comfort. An 18-gauge cannula (choice A) may be too large and cause discomfort, while 22-gauge (choice C) and 24-gauge (choice D) may not allow for adequate fluid administration in a timely manner.
Question 5 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.