ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
The nurse is caring for a patient in transition. Which sign is most indicative that this phase of labor is occurring?
Correct Answer: B
Rationale: The correct answer is B because increased bloody show and complaints of pressure are indicative of the transition phase of labor. This phase occurs when the cervix dilates from 8 to 10 cm and contractions are strong and close together. This is a sign that the baby is moving down the birth canal. The other choices are incorrect because A describes the active phase of labor, C indicates the second stage of labor, and D reflects early labor. B is the most appropriate choice as it specifically aligns with the characteristics of the transition phase.
Question 2 of 5
A patient in active labor is experiencing hypotension after receiving an epidural block. What is the nurse's first action?
Correct Answer: C
Rationale: The correct answer is C. Placing the patient in a side-lying position is the first action because it helps to improve venous return, cardiac output, and blood pressure by increasing blood flow to the heart and brain. This can help alleviate hypotension associated with epidural block. Elevating the legs (choice B) may not be as effective in improving blood flow in this situation. Administering a fluid bolus (choice A) may be necessary but should not be the initial action. Notifying the anesthesiologist (choice D) is important, but addressing the patient's immediate physiological needs should come first.
Question 3 of 5
The nurse is preparing to perform Leopold's maneuvers. Please select the rationale for the consistent use of these maneuvers by obstetric providers?
Correct Answer: C
Rationale: The correct answer is C because Leopold's maneuvers are used to determine the best location to assess the fetal heart rate. Step 1: Palpate the fundus to identify the fetal part. Step 2: Determine the fetal back to locate the fetal heart sounds. Step 3: Identify the presenting part. Step 4: Determine the position of the fetal head. This systematic approach helps assess fetal well-being. Choices A and B are incorrect because Leopold's maneuvers focus on fetal position and presentation, not membrane status or cervical dilation. Choice D is incorrect as it pertains to the fetal position, which is not the primary purpose of Leopold's maneuvers.
Question 4 of 5
Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?
Correct Answer: D
Rationale: The correct answer is D. Saturation of two perineal pads in 4 hours is an indication of hemorrhage postpartum. This is because excessive bleeding after delivery can lead to soaking through pads quickly. A: Elevated pulse rate can be a sign of shock but not specific to hemorrhage. B: Elevated blood pressure is not a typical sign of hemorrhage. C: A firm fundus at the midline is a normal finding postpartum and not indicative of hemorrhage.
Question 5 of 5
A patient at 40 weeks' gestation should be instructed to go to a hospital or birth center for evaluation when she experiences
Correct Answer: C
Rationale: The correct answer is C because a trickle of fluid from the vagina at 40 weeks' gestation could indicate the rupture of membranes, which is a sign of impending labor. This warrants immediate evaluation to assess the status of the amniotic sac and the need for monitoring or intervention. Explanation for other choices: A: Increased fetal movement is a normal sign of fetal well-being and not a reason for immediate evaluation. B: Irregular contractions for 1 hour may not necessarily indicate active labor, so immediate evaluation is not needed. D: Thick pink or dark red vaginal mucus may indicate bloody show, which can be a sign of labor starting, but it is not as urgent as a potential rupture of membranes.