ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
Correct Answer: A
Rationale: The correct action is to assess the infant for signs of trauma (Choice A) because forceps-assisted birth can increase the risk of injury to the infant. By assessing for signs of trauma promptly, the nurse can identify any potential issues and initiate necessary interventions. Choice B is incorrect because measuring the circumference of the infant's head is not necessary immediately after forceps-assisted birth. Choice C is incorrect as applying a cold pack to the infant's scalp is not indicated unless there is a specific medical reason for it. Choice D is incorrect because giving prophylactic antibiotics to the infant is not a standard practice following forceps-assisted birth unless there is a specific indication for infection prevention.
Question 2 of 5
Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?
Correct Answer: B
Rationale: The correct answer is B: Symmetry of facial movements. Bruising over the cheeks can indicate potential nerve damage from the forceps birth. Assessing facial movements helps determine if there is any nerve injury affecting facial muscles. Presence of newborn reflexes (A) is important but not directly related to facial nerve injury. Caput and molding of the head (C) are more related to the birthing process and not specific to facial nerve assessment. Anterior and posterior fontanels (D) are important for assessing fontanelle closure but not specific to facial nerve evaluation.
Question 3 of 5
Following an external cephalic version, which assessment finding indicates a complication?
Correct Answer: C
Rationale: The correct answer is C: Deceleration of FHR to 88 bpm. This finding indicates fetal distress, a complication post external cephalic version. Deceleration of FHR suggests reduced oxygenation to the fetus. A: Onset of irregular contractions is a common post-procedure finding and not necessarily indicative of a complication. B: Maternal blood pressure of 110/70 mm Hg is within normal range and not directly related to a complication. D: Maternal pulse rate of 100 bpm is slightly elevated but not a specific indicator of a complication post external cephalic version.
Question 4 of 5
The labor nurse is developing a plan of care for a patient admitted in active labor with
Correct Answer: A
Rationale: The correct answer is A: On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). The priority nursing action for this patient is to assess the vital signs. The maternal heart rate, fetal heart rate, blood pressure, and temperature are crucial indicators of the patient's and the fetus's well-being during labor. Monitoring these vital signs helps the nurse detect any abnormalities or signs of distress promptly, allowing for timely intervention. Choice B, fetal acoustic stimulation, is not the priority at this stage as there are no indications in the question stem that suggest the need for this intervention. Choice C, assessing temperature every 2 hours, is not the priority as the patient's temperature is within normal range on admission. Choice D, changing absorption pads under her hips every 2 hours,
Question 5 of 5
When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Monitor and record vital signs frequently during the course of labor. This is essential to ensure the patient's physiological stability and detect any deviations that may indicate complications. Checking the DTR (Choice A) is not relevant for low-risk patients in labor. Documenting the FHR pattern (Choice C) is important, but not as crucial as monitoring vital signs. Indicating maternal position changes on the EFM tracing (Choice D) is beneficial but not a priority assessment for low-risk patients. Vital sign monitoring is the most critical assessment for ensuring the well-being of the patient in labor.