ATI RN
External Maternal Monitoring Questions
Question 1 of 5
The nurse is caring for a pregnant patient at 36 weeks gestation who reports sudden, severe headache and blurred vision. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B because sudden severe headache and blurred vision in a pregnant patient at 36 weeks gestation are potential signs of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Monitoring the patient's blood pressure and checking for signs of preeclampsia is crucial for early detection and timely intervention. Administering pain medication (choice A) may mask symptoms and delay appropriate treatment. Encouraging rest and fluids (choice C) may not address the underlying cause of the symptoms. Scheduling a follow-up appointment (choice D) may delay necessary immediate actions to address potential preeclampsia.
Question 2 of 5
A pregnant patient is at 24 weeks gestation and reports occasional cramping and lower abdominal discomfort. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Assess for signs of preterm labor and monitor the patient for regular contractions. This is the most appropriate action as the patient is experiencing cramping and lower abdominal discomfort, which could indicate preterm labor. Step 1: Assessing for signs of preterm labor, such as regular contractions, is crucial to determine the patient's condition. Step 2: Monitoring the patient for regular contractions helps in identifying any patterns and assessing the progression of labor. Other choices are incorrect as B: Administering pain medications without assessing for preterm labor can mask important indicators. C: Performing a pelvic exam may increase the risk of infection and is not the priority. D: Instructing the patient to increase fluid intake may not address the potential risk of preterm labor.
Question 3 of 5
A pregnant patient at 36 weeks gestation reports difficulty breathing when lying flat. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A because positioning the patient in a semi-reclined or left side position can alleviate pressure on the diaphragm and improve breathing. This position helps optimize blood flow to the uterus and placenta. Encouraging rest in this position can improve oxygenation for both the mother and fetus. Administering oxygen (Choice B) may help with oxygenation but does not address the underlying issue of positional discomfort. Monitoring fetal heart rate (Choice C) is important but not the first action to address the mother's breathing difficulty. Instructing the patient to take shallow breaths and stay in bed (Choice D) does not address the positional component of the issue.
Question 4 of 5
A pregnant patient is at 28 weeks gestation and reports occasional headaches and blurred vision. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. 1. Headaches and blurred vision are common symptoms of preeclampsia. 2. Preeclampsia is a serious condition that can lead to complications for both the mother and baby. 3. Monitoring blood pressure is crucial in diagnosing preeclampsia and determining the appropriate course of action. 4. Prompt assessment and management of preeclampsia are essential to prevent further complications. Incorrect choices: B: Administering pain relief and encouraging rest does not address the underlying cause of the symptoms, which could be preeclampsia. C: Assessing vision and scheduling an appointment with an eye specialist does not address the urgent need to assess for preeclampsia. D: Encouraging fluid intake and avoiding strenuous activity may be helpful in general, but they do not address the potential seriousness of preeclampsia in this
Question 5 of 5
In a low-risk laboring person who is not receiving oxytocin, how often should the nurse assess the fetal heart rate during the second stage of labor?
Correct Answer: C
Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.