ATI RN
Maternity Heartbeat Monitor Questions
Question 1 of 5
The nurse is caring for a pregnant patient who is 22 weeks gestation and has a history of gestational hypertension. What should the nurse monitor most closely?
Correct Answer: B
Rationale: The correct answer is B: Protein in the urine to assess for preeclampsia. The nurse should closely monitor protein in the urine because the patient has a history of gestational hypertension, which puts her at risk for developing preeclampsia. Preeclampsia is characterized by high blood pressure and proteinuria. Monitoring protein in the urine helps detect early signs of preeclampsia, which can lead to serious complications for both the mother and the fetus if left untreated. Blood glucose levels (A) are not the priority in this case, as the patient's history indicates a higher risk for preeclampsia. Fetal heart rate (C) and daily weight gain (D) are important aspects to monitor during pregnancy; however, in this scenario, the focus should be on detecting signs of preeclampsia due to the patient's history of gestational hypertension.
Question 2 of 5
A pregnant patient is at 24 weeks gestation and reports pain in her lower abdomen and back. What is the nurse's first priority action?
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for signs of preterm labor, including regular contractions. At 24 weeks gestation, lower abdomen and back pain could be indicative of preterm labor. Therefore, the nurse's first priority should be to assess the patient for signs of preterm labor, such as regular contractions, vaginal bleeding, pelvic pressure, or changes in vaginal discharge. This is crucial to determine if the patient and the fetus are in any immediate danger. Administering pain medication (choice A), instructing relaxation techniques (choice C), or encouraging exercise (choice D) are not appropriate initial actions as they do not address the potential serious issue of preterm labor.
Question 3 of 5
A pregnant patient at 32 weeks gestation reports increased pressure in the pelvic area and mild cramping. What should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A: The fetal heart rate and signs of labor. At 32 weeks gestation, any pelvic pressure and cramping could be indicative of preterm labor, which is a critical concern. Assessing the fetal heart rate can help determine fetal well-being and signs of distress. Monitoring for signs of labor such as contractions, cervical changes, and rupture of membranes is essential for timely intervention. Choice B: Assessing blood pressure and urine for protein is important in monitoring for preeclampsia, but it is not the priority in this case where signs of preterm labor are reported. Choice C: Vaginal discharge or bleeding could indicate various conditions, but in this scenario, the focus should be on ruling out preterm labor first. Choice D: Dietary intake and hydration status are important aspects of prenatal care, but they are not the priority when assessing a pregnant patient reporting pelvic pressure and cramping at 32 weeks gestation.
Question 4 of 5
A pregnant patient at 28 weeks gestation reports feeling nauseated and vomiting after meals. What is the most appropriate action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Recommend the patient eat smaller, more frequent meals and avoid greasy foods. This is because smaller, more frequent meals can help alleviate nausea and vomiting during pregnancy by preventing the stomach from becoming too full. Greasy foods can exacerbate nausea, so avoiding them is beneficial. A: Encouraging large meals less frequently can worsen symptoms by overwhelming the digestive system. C: Resting after meals may not directly address the underlying cause of nausea and vomiting. D: Avoiding all foods can lead to inadequate nutrition for both the patient and the developing fetus. In summary, choice B is the most appropriate as it addresses the symptoms effectively and promotes better nutrition during pregnancy.
Question 5 of 5
A pregnant patient at 34 weeks gestation is concerned about swelling in her hands, feet, and face. 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. At 34 weeks gestation, swelling in the hands, feet, and face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and proteinuria. Monitoring blood pressure is crucial to identify any preeclampsia development. Preeclampsia can lead to complications for both the mother and the baby if left untreated. Other choices are incorrect because B may provide temporary relief but does not address the underlying concern, C should not be done without confirming the diagnosis, and D focuses on fluid intake and sodium intake but does not address the need to assess for preeclampsia.