ATI RN
Needs of Maternal and Reproductive Health Clients Questions
Question 1 of 5
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
Correct Answer: A
Rationale: In this scenario, option A is the correct answer because edema, basilar rales, and an irregular pulse are indicative of worsening heart failure in a pregnant woman with pre-existing heart disease during the second stage of labor. Option B, increased urinary output, and tachycardia could be normal physiological responses during labor and may not necessarily indicate a complication related to the woman's heart disease. Option C, dyspnea, bradycardia, and hypertension are also concerning symptoms, but in the context of a woman with pre-existing heart disease, these findings might suggest other issues rather than worsening heart failure. Option D, a regular heart rate, and hypertension is not as concerning as the symptoms listed in option A, as hypertension alone may be managed in a woman with pre-existing heart disease. Educationally, this question highlights the importance of recognizing the unique needs and risks associated with maternal and reproductive health clients, especially those with pre-existing conditions. It emphasizes the necessity of thorough assessment and critical thinking in identifying potential complications during labor and delivery to provide safe and effective care for both the mother and the baby.
Question 2 of 5
A primigravida at 39-weeks gestation is admitted to the labor and delivery unit in active labor. She is given an epidural anesthetic. Her blood pressure drops to 90/50 mm Hg, and the fetal heart rate shows late decelerations. What is the most likely cause of these findings?
Correct Answer: A
Rationale: In this scenario, the most likely cause of the findings (maternal hypotension, late decelerations in fetal heart rate) is A) Maternal hypotension. When a pregnant woman receives an epidural, it can lead to a drop in blood pressure due to sympathetic blockade, leading to decreased perfusion to the placenta and subsequent fetal distress. This is a common complication during labor and delivery. Maternal hypotension can result in reduced oxygen and nutrient delivery to the fetus, manifesting as late decelerations in the fetal heart rate. Option B) Uteroplacental insufficiency is less likely in this case because it typically presents with persistent fetal heart rate abnormalities rather than acute changes seen with maternal hypotension. Option C) Fetal distress is a consequence of the primary issue of maternal hypotension causing decreased perfusion to the fetus. Option D) Amniotic fluid embolism would present with more severe and sudden symptoms such as cardiovascular collapse and respiratory distress, which are not evident in this scenario. Educationally, understanding the physiological responses to epidural anesthesia and its potential complications is crucial for healthcare providers managing laboring patients. Recognizing and promptly addressing maternal hypotension can help mitigate adverse effects on both the mother and the fetus during childbirth.
Question 3 of 5
A client at 38-weeks gestation is admitted to the labor and delivery unit with mild contractions every 5 minutes. The client's cervix is dilated 2 cm, 50% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take next is to monitor the fetal heart rate pattern (Option A). This is crucial because the client's membranes have ruptured, indicating that the client is at risk for infection due to the loss of the amniotic fluid's protective barrier. Monitoring the fetal heart rate helps assess the well-being of the fetus and can indicate any signs of distress or compromise, enabling timely interventions. Performing a vaginal examination (Option B) at this point can increase the risk of introducing infection, given that the membranes have already ruptured. Encouraging the client to ambulate (Option C) may not be suitable due to the need for close monitoring after membrane rupture. Administering pain medication (Option D) is not the priority at this moment, as fetal assessment takes precedence to ensure the well-being of both the mother and the baby. From an educational perspective, it is vital for nurses to understand the sequence of actions to take in managing a client in labor, especially when complications arise. This case emphasizes the importance of prioritizing fetal well-being and infection prevention strategies in maternal and reproductive health care settings.
Question 4 of 5
A client at 32-weeks gestation is admitted to the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. The client's blood pressure is 150/100 mm Hg. What condition should the nurse suspect?
Correct Answer: B
Rationale: In this scenario, the nurse should suspect preeclampsia as the correct condition. Preeclampsia is characterized by high blood pressure (hypertension), protein in the urine, and often involves symptoms like severe headache, visual disturbances, and epigastric pain. The presence of hypertension (150/100 mm Hg) along with the client's symptoms is indicative of preeclampsia, a serious condition that can lead to complications for both the mother and the baby if not managed promptly. Gestational hypertension (Option A) is high blood pressure that develops after 20 weeks of pregnancy but without the presence of protein in the urine or other signs of preeclampsia. Eclampsia (Option C) is a severe complication of preeclampsia characterized by seizures. Chronic hypertension (Option D) is high blood pressure that was present before pregnancy or diagnosed before 20 weeks of pregnancy. Educationally, understanding the differences between these conditions is crucial for nurses caring for maternal and reproductive health clients. Recognizing the signs and symptoms of preeclampsia, such as elevated blood pressure and associated symptoms, allows for timely intervention and management to prevent serious complications for both the mother and the baby. Early identification and appropriate management are key in providing safe and effective care to pregnant individuals.
Question 5 of 5
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 6 cm, 90% effaced, and the fetus is at 0 station. The client's membranes rupture spontaneously, and the fluid is clear. What action should the nurse take next?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take next is to monitor the fetal heart rate pattern. This is crucial as the client is in active labor, and monitoring the fetal heart rate helps assess the well-being of the fetus during this critical stage. Performing a vaginal examination (Option B) may increase the risk of infection since the membranes have already ruptured. Encouraging the client to ambulate (Option C) may not be suitable at this point due to the stage of labor and the need for continuous monitoring. Administering pain medication (Option D) could be considered based on the client's pain level, but ensuring fetal well-being through continuous fetal heart rate monitoring takes precedence in this situation. From an educational standpoint, understanding the significance of fetal heart rate monitoring in labor is crucial for ensuring optimal maternal and fetal outcomes. It allows for early identification of any potential issues, enabling prompt intervention if needed. Students and healthcare providers must prioritize fetal assessment during labor to provide safe and effective care for maternal and reproductive health clients.