ATI RN
Pregnancy Assessment Questions Questions
Question 1 of 5
The nurse is caring for a client who is scheduled to have an amniocentesis. Which intervention is most important for the nurse to perform after the procedure?
Correct Answer: A
Rationale: The correct answer is A: Evaluate need for Rh0D immunoglobulin. After an amniocentesis, it is crucial to assess if the client is Rh-negative and the fetus is Rh-positive. If this is the case, Rh0D immunoglobulin should be administered to prevent Rh incompatibility issues in future pregnancies. This intervention is critical to prevent hemolytic disease in the newborn. Cleaning the site (B) is important for infection prevention but not the most critical post-procedure intervention. Administering pain medication (C) can be done based on client's discomfort level but not the top priority. Performing vital signs (D) is important but assessing Rh status and administering Rh0D immunoglobulin take precedence.
Question 2 of 5
The nurse is preparing to teach a client how to perform daily fetal kick counts. Which instruction is most important for the nurse to give the client?
Correct Answer: C
Rationale: The correct answer is C: Call provider if at least three movements are not felt in 1 hour. This instruction is crucial because decreased fetal movements can indicate potential fetal distress. By advising the client to contact the healthcare provider if fewer than three movements are felt in an hour, the nurse is emphasizing the importance of promptly seeking medical attention when there may be a concern for the baby's well-being. A: Counting kicks prior to eating a meal is not as important as monitoring the baby's movements consistently throughout the day. B: Lying on the back when counting kicks is not recommended, as it can reduce blood flow to the uterus and potentially affect the baby. D: Counting all movements over 1 hour may not capture a decrease in movements that could be a cause for concern, as the focus should be on monitoring a specific minimum number of movements within a set timeframe. In summary, the correct answer emphasizes the need for prompt action in case of decreased fetal movements, while
Question 3 of 5
The nurse is admitting a client, who reports, 'My water broke yesterday, and I haven't felt my baby move any today.' She is 38 weeks with a history of gestational diabetes. Which assessment data is of most concern to the nurse on admission?
Correct Answer: C
Rationale: The correct answer is C because minimal variability and variable decelerations on fetal heart monitoring indicate fetal distress, which is a critical concern. Minimal variability suggests the baby's nervous system is compromised, and decelerations can indicate umbilical cord compression or placental insufficiency, possibly leading to fetal hypoxia. This situation requires immediate intervention to prevent potential harm to the baby. Choice A is incorrect as the vital signs are slightly elevated but not as concerning as fetal distress. Choice B is incorrect as pain score is subjective and not as critical as fetal well-being. Choice D is incorrect as cervical dilation/effacement/station is important for labor progress but not as concerning as fetal distress in this scenario.
Question 4 of 5
The nurse reports a nonreactive NST to the physician. The physician orders vibroacoustic stimulation. Which does the nurse understand the appropriate application for the vibroacoustic stimulation to be? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Apply the artificial larynx stimulus by the fetal head. Vibroacoustic stimulation involves using sound waves to stimulate the fetus and provoke a response, particularly in cases of nonreactive nonstress test (NST). By applying the artificial larynx stimulus near the fetal head, the nurse ensures direct and effective stimulation of the fetus. This method has been found to be safe and effective in improving fetal heart rate reactivity. Incorrect Choices: A: Clap loudly by the fetal head - This is not an appropriate method for vibroacoustic stimulation as it may not provide the controlled and targeted stimulation needed. B: Apply a sterile drape to abdomen prior to stimulation - This is not necessary for vibroacoustic stimulation and does not contribute to its effectiveness. D: Limit the use of the artificial larynx stimulus to three times - There is no specific limit to the number of times vibroacoustic stimulation can be applied, as it depends on the
Question 5 of 5
Which laboratory is important to know when a client is having an amniocentesis?
Correct Answer: C
Rationale: Step-by-step rationale: 1. Rh factor is crucial to know to prevent Rh incompatibility issues during pregnancy. 2. Amniocentesis can pose a risk for Rh sensitization in Rh-negative mothers. 3. Knowing the Rh status helps determine if Rhogam (anti-D) is needed after amniocentesis. 4. Blood type (A) and CBC (B) are important but not directly relevant to amniocentesis. 5. PT and PTT (D) are coagulation tests, typically not required for routine amniocentesis.