ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 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 2 of 5
The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Soft boggy uterus. In the fourth stage of labor, the uterus should be firm and well-contracted to prevent postpartum hemorrhage. A soft, boggy uterus indicates uterine atony, a potential complication that can lead to excessive bleeding. B: Maternal temperature of 37.2°C (99F) is within normal range and not indicative of a complication. C: High uterine fundus displaced to the right could indicate a full bladder or uterine displacement, but it is not a direct sign of a complication in the fourth stage of labor. D: Intense vaginal pain unrelieved by analgesics may be due to various reasons but is not a typical complication in the fourth stage of labor.
Question 3 of 5
What technique, usually reserved for low-risk persons, has been shown to decrease pain, encourage movement, decrease anxiety, shorten labor, and improve labor satisfaction?
Correct Answer: D
Rationale: The correct answer is D: hydrotherapy. Hydrotherapy involves the use of water for pain relief and relaxation during labor. It helps decrease pain by providing buoyancy and reducing the pressure on joints. The warm water encourages movement and relaxation, which can shorten labor duration and improve satisfaction. Controlled breathing (A) can be helpful but may not provide the same physical benefits as hydrotherapy. Aromatherapy (B) may help with relaxation but does not have the same direct physical effects on pain and movement. Massage (C) can be beneficial, but hydrotherapy offers a more comprehensive approach to pain management and labor support.
Question 4 of 5
What is the term for a slow, deep inhalation through the nose and exhalation through the mouth before a contraction for preparation and after a contraction for release of tension from the contraction?
Correct Answer: D
Rationale: The correct answer is D: cleansing breath. This technique involves slow, deep inhalation through the nose and exhalation through the mouth to release tension. Pursed-lip breathing (A) is used for managing shortness of breath. Panting (B) is rapid, shallow breathing. Chanting (C) involves rhythmic speaking or singing. Cleansing breath (D) fits the description best as it focuses on deep, intentional breathing for relaxation and release of tension before and after a contraction.
Question 5 of 5
The laboring person is using hypnosis for comfort measures. How can the nurse support the person?
Correct Answer: C
Rationale: The correct answer is C because keeping the room quiet and dimly lit promotes relaxation and helps the person stay focused during hypnosis. Bright lights and noise can be distracting and increase stress levels. Talking them through contractions (Choice A) may disrupt their concentration on hypnosis. Asking them to rate pain during contractions (Choice D) can also be disruptive and may increase anxiety.