ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 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 2 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.
Question 3 of 5
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions. A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period. C is incorrect as last food intake and cultural practices are not the most critical assessments during labor. D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
Question 4 of 5
Which clinical finding would be an indication to the nurse that the fetus may be compromised?
Correct Answer: D
Rationale: The correct answer is D. Meconium-stained amniotic fluid indicates fetal distress due to possible hypoxia. Meconium in the fluid can lead to meconium aspiration syndrome, a serious condition. The other choices are incorrect because active fetal movements (A) and a fetal heart rate in the 140s (B) are normal signs of fetal well-being. Contractions lasting 90 seconds (C) could indicate labor progress but do not necessarily indicate fetal compromise.
Question 5 of 5
During labor a vaginal examination should be performed only when necessary because of the risk of
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection. Step 2: Infections can be harmful to both the mother and the baby. Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection. Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.