ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?
Correct Answer: B
Rationale: The correct answer is B: 20-gauge. During active labor, a larger IV cannula is recommended to accommodate rapid fluid administration and potential blood loss. A 20-gauge cannula provides a good balance between flow rate and patient comfort. An 18-gauge cannula (choice A) may be too large and cause discomfort, while 22-gauge (choice C) and 24-gauge (choice D) may not allow for adequate fluid administration in a timely manner.
Question 2 of 5
A maternal indication for the use of vacuum extraction is
Correct Answer: B
Rationale: The correct answer is B: maternal exhaustion. Vacuum extraction may be indicated when the mother is too exhausted to continue pushing, as it can assist in the delivery process. A wide pelvic outlet (choice A) may facilitate delivery but is not a specific indication for vacuum extraction. A history of rapid deliveries (choice C) does not necessarily require vacuum extraction. Failure to progress past 0 station (choice D) may indicate other interventions like cesarean section rather than vacuum extraction. Therefore, the most appropriate indication for vacuum extraction in this scenario is maternal exhaustion.
Question 3 of 5
Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
Correct Answer: A
Rationale: The correct action is to assess the infant for signs of trauma (Choice A) because forceps-assisted birth can increase the risk of injury to the infant. By assessing for signs of trauma promptly, the nurse can identify any potential issues and initiate necessary interventions. Choice B is incorrect because measuring the circumference of the infant's head is not necessary immediately after forceps-assisted birth. Choice C is incorrect as applying a cold pack to the infant's scalp is not indicated unless there is a specific medical reason for it. Choice D is incorrect because giving prophylactic antibiotics to the infant is not a standard practice following forceps-assisted birth unless there is a specific indication for infection prevention.
Question 4 of 5
The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of her patient. With which patient should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?
Correct Answer: D
Rationale: The correct answer is D because a patient with previous surgery in the upper uterus is at risk for uterine rupture with prostaglandin use. Previous surgery in the upper uterus may weaken the uterine wall, increasing the risk of complications such as uterine rupture during cervical ripening. A: Bishop's score of 5 indicates a moderate readiness for induction, making vaginal prostaglandin appropriate. B: 42 weeks of gestation is considered post-term, where cervical ripening is often needed. C: Previous low transverse cesarean birth is not a contraindication for prostaglandin use for cervical ripening.
Question 5 of 5
Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?
Correct Answer: B
Rationale: The correct answer is B: Symmetry of facial movements. Bruising over the cheeks can indicate potential nerve damage from the forceps birth. Assessing facial movements helps determine if there is any nerve injury affecting facial muscles. Presence of newborn reflexes (A) is important but not directly related to facial nerve injury. Caput and molding of the head (C) are more related to the birthing process and not specific to facial nerve assessment. Anterior and posterior fontanels (D) are important for assessing fontanelle closure but not specific to facial nerve evaluation.