ATI RN
Possible Complications in Early Pregnancy Questions
Question 1 of 5
The nurse should reply to a pregnant woman experiencing significant nausea and vomiting by stating:
Correct Answer: C
Rationale: The correct answer is C because it is a common occurrence for nausea and vomiting to improve by the beginning of the second trimester of pregnancy. This is due to hormonal changes and adjustments in the body. Option D is not the correct answer as the improvement usually occurs earlier than when the baby starts to move. Option A is not relevant to the situation, and option B is inaccurate as nausea and vomiting typically improve before the third trimester.
Question 2 of 5
When auscultating the anterior thorax of a pregnant woman, the nurse notices the presence of a murmur over the second, third, and fourth intercostal spaces. The murmur is continuous but can be obliterated by pressure with the stethoscope or finger on the thorax just lateral to the murmur. The nurse interprets this finding to be:
Correct Answer: B
Rationale: This finding is most likely a mammary souffle. A mammary souffle is a benign vascular hum heard over the breasts during pregnancy due to increased blood flow to the breasts. It is typically heard over the second, third, and fourth intercostal spaces and is continuous. The fact that pressure with the stethoscope or finger can obliterate the sound supports this interpretation, as mammary souffles are typically easily influenced by pressure. A: A murmur of aortic stenosis is typically heard over the aortic area, which is the second intercostal space at the right sternal border. It is a systolic murmur with a crescendo-decrescendo quality and is not influenced by pressure. C: A murmur associated with aortic insufficiency is typically heard over the aortic area and radiates to the carotids. It is a diastolic murmur and is not influenced by pressure. D: An indication of a patent ductus arteriosus would present with a continuous murmur typically heard over the left infraclavicular area. It is not influenced by pressure and would not be heard over the second, third, and fourth intercostal spaces.
Question 3 of 5
When performing an examination of a woman who is 34 weeks pregnant, the nurse notices a midline linear protrusion in the abdomen over the area of the rectus abdominis muscles as the woman raises her head and shoulders off of the bed. Which response by the nurse is correct?
Correct Answer: D
Rationale: Option A is incorrect because the protrusion seen in the abdomen is not indicative of diastasis recti, which is the separation of the rectus abdominis muscles. Diastasis recti is a common condition during pregnancy but is not typically visible when the woman raises her head and shoulders off the bed. Option B is incorrect because the protrusion seen in the abdomen is not necessarily a condition that requires surgical repair. It is important to assess further and gather more information before jumping to conclusions about the need for surgery. Option C is incorrect because while a hernia is a possibility, it is not the only explanation for the midline linear protrusion seen in the abdomen. There are other factors that could contribute to this presentation, and further assessment is needed to determine the cause. Option D is the correct answer because it highlights the need for further assessment and evaluation before making any definitive conclusions or recommendations. The nurse should continue to gather information, possibly consult with the physician, and monitor the situation to determine the appropriate course of action. It is essential to avoid jumping to conclusions or making assumptions without a thorough assessment.
Question 4 of 5
During the assessment of a woman in her 22nd week of pregnancy, the nurse is unable to hear fetal heart tones with the fetoscope. The nurse should:
Correct Answer: D
Rationale: Answer D is correct because using ultrasound to verify cardiac activity is the most appropriate action when fetal heart tones cannot be heard with a fetoscope. Ultrasound is a non-invasive and highly accurate method to assess fetal well-being and can provide immediate visual confirmation of cardiac activity, reassuring both the healthcare provider and the pregnant woman. Answer A is incorrect because immediately notifying the physician and then waiting 10 minutes to try again does not address the underlying issue of the inability to hear fetal heart tones. Waiting without taking any further action could delay necessary interventions if there is a concern about fetal well-being. Answer B is incorrect because asking the woman if she has felt the baby move today does not provide objective evidence of fetal well-being. Fetal movement can vary and may not always be an accurate indicator of fetal cardiac activity. It is important to rely on more concrete methods, such as ultrasound, to assess fetal well-being. Answer C is incorrect because simply waiting 10 minutes and trying again with the fetoscope does not address the initial concern of not being able to hear fetal heart tones. If there is a genuine concern about fetal well-being, it is essential to take proactive steps, such as using ultrasound, to assess the situation accurately and promptly.
Question 5 of 5
During auscultation of fetal heart tones (FHTs), the nurse determines that the heart rate is 136 beats per minute. The nurse's next action should be to:
Correct Answer: A
Rationale: The normal fetal heart rate falls between 110 and 160 beats per minute, so the nurse should document the results as within the normal range. There is no indication of fetal distress based on the heart rate provided. Verifying with the maternal pulse or having the patient change positions is unnecessary in this scenario.