ATI RN
Advanced Maternal Age Monitoring Questions
Question 1 of 5
The nurse is assessing a pregnant patient who is 30 weeks gestation and reports pain in the lower abdomen and back. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A because pain in the lower abdomen and back could indicate preterm labor at 30 weeks gestation. The first step is to assess for signs of preterm labor, such as regular contractions, to determine the urgency of the situation. Administering pain medication (B) without assessing the cause can mask symptoms. Encouraging physical activity (C) may worsen preterm labor. Instructing the patient to lie flat on her back (D) can decrease blood flow to the uterus and is not recommended in late pregnancy.
Question 2 of 5
A laboring person on oxytocin for induction of labor should have continuous monitoring of the fetal heart rate. How often should the nurse assess the fetal heart rate?
Correct Answer: B
Rationale: The correct answer is B: every 15 minutes. Continuous monitoring of the fetal heart rate is crucial during labor induction with oxytocin to promptly detect any signs of fetal distress. Assessing the fetal heart rate every 15 minutes allows for frequent monitoring to ensure the baby's well-being and timely intervention if needed. Assessing every 30 minutes (choice A) may not provide adequate monitoring frequency, every 5 minutes (choice C) is too frequent and may not be practical, and every 1 hour (choice D) is too long of an interval between assessments, potentially missing important changes in fetal status.
Question 3 of 5
During the postpartum period, a nurse is caring for a birthing person who is receiving uterotonic medications. The nurse's assessment reveals a boggy and enlarged uterus. What is the nurse's immediate action?
Correct Answer: C
Rationale: The correct immediate action is C: Perform fundal massage to promote uterine firmness. Fundal massage helps prevent postpartum hemorrhage by promoting uterine contraction and firmness. A: Documenting the findings as normal is incorrect as a boggy and enlarged uterus is not a normal finding postpartum. B: Continuing to administer uterotonic medication without addressing the boggy uterus can lead to ineffective contraction. D: Administering an analgesic for pain does not address the underlying issue of uterine atony.
Question 4 of 5
A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?
Correct Answer: A
Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.
Question 5 of 5
A nurse is caring for a postpartum person with a diagnosis of uterine atony. What is the most appropriate first action to take?
Correct Answer: A
Rationale: The correct first action is to perform fundal massage. This helps stimulate uterine contractions, which can help control bleeding due to uterine atony. The massage should be done gently but firmly to prevent further complications. Administering uterotonic medication (choice B) can be done after fundal massage. Performing a vaginal exam (choice C) can increase the risk of infection and should be avoided initially. Monitoring vital signs (choice D) is important but addressing the uterine atony should be the priority to prevent further complications.