ATI RN
Intrapartum Complications NCLEX Questions Questions
Question 1 of 5
The nurse is reviewing an electronic fetal monitor tracing from a patient in active labor and notes the fetal heart rate gradually drops to 20 beats per minute (bpm) below the baseline and returns to the baseline well after the completion of the patient's contractions. How will the nurse document these findings?
Correct Answer: B
Rationale: The correct answer is B: Early decelerations. Early decelerations occur in response to fetal head compression during contractions, resulting in a gradual decrease in the fetal heart rate that mirrors the timing of contractions. In this scenario, the fetal heart rate drops to 20 bpm below the baseline during contractions and returns to baseline after contractions, indicating a benign pattern. Late decelerations (choice A) occur after the peak of the contraction and are associated with uteroplacental insufficiency. Variable decelerations (choice C) are abrupt decreases in fetal heart rate without a consistent timing in relation to contractions, often due to cord compression. Proximal decelerations (choice D) are not a recognized classification of decelerations in fetal monitoring.
Question 2 of 5
When assessing a prenatal client at follow-up prenatal visits during the second trimester, the nurse should anticipate which assessments to be performed at each visit? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Weight, height, BMI. During each second-trimester prenatal visit, it is essential to monitor the client's weight, height, and BMI to ensure appropriate maternal and fetal health. Weight gain is a crucial indicator of fetal growth and maternal well-being. Height and BMI can provide insights into the client's nutritional status and overall health. Explanation of why other choices are incorrect: A: Cervical examination is typically not performed routinely during second-trimester prenatal visits unless there are specific concerns such as preterm labor risk. C: Fetal ultrasound is usually scheduled at specific times during pregnancy, not necessarily at every second-trimester visit. D: Fundal height measurement is important, but it is usually performed starting in the second trimester to assess fetal growth and position, not necessarily at every visit.
Question 3 of 5
Which statement by the patient indicates to the nurse that the patient understands danger signs during the second trimester?
Correct Answer: C
Rationale: The correct answer is C because pain while urinating can be a sign of a urinary tract infection, which is common during pregnancy and can lead to complications if not treated promptly. Heartburn, constipation, and leg cramps are common discomforts during pregnancy but are not typically considered emergency danger signs. Therefore, option C is the most critical symptom that requires immediate medical attention to prevent potential harm to the mother and baby.
Question 4 of 5
The nurse is assessing the client for the presence of ballottement. Which should the nurse perform to test for the presence of ballottement?
Correct Answer: C
Rationale: The correct answer is C. To test for the presence of ballottement, the nurse should initiate a gentle upward tap on the cervix. Ballottement is a technique used in obstetrics to assess for the presence of a floating object in the uterus, such as a fetus. By tapping the cervix gently, the nurse can feel for a rebound effect, indicating the presence of a floating object. This technique helps to confirm the presence of a fetus in the uterus. Explanation of why other choices are incorrect: A: Palpating the uterus for contractions is not relevant to testing for ballottement. B: Assessing the skin for increased pigmentation is not related to assessing for the presence of a floating object in the uterus. D: Palpating the abdomen for fetal outline does not specifically test for ballottement, which involves tapping the cervix.
Question 5 of 5
A nurse is taking a birth history assessment on a client who is 8 weeks gestation and has one child who was born at 38 weeks. Which is consistent with this birth history?
Correct Answer: D
Rationale: The correct answer is D: Multipara. This term refers to a woman who has given birth to two or more children. In this case, the client has one child already, making her a multipara. A: Primipara refers to a woman who has given birth to one child, which does not match the client's birth history. B: Primigravida refers to a woman who is pregnant for the first time, which also does not match the client's history. C: Nulligravida refers to a woman who has never been pregnant, which is not the case for the client. Therefore, the correct term to describe the client's birth history is Multipara, as she has one child and is currently 8 weeks gestation.