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: In this scenario, the nurse is likely detecting a mammary souffle. A mammary souffle is a benign vascular murmur heard over the breasts of pregnant or lactating women. This type of murmur is usually continuous, can be obliterated by applying pressure just lateral to it, and is typically heard over the second to fourth intercostal spaces. It is considered a normal finding in pregnancy due to increased blood flow in the breasts. The other options can be ruled out based on the clinical presentation and characteristics of the murmur described. Aortic stenosis and aortic insufficiency murmurs are typically associated with different characteristics and locations. A patent ductus arteriosus murmur would have a different quality and location than what is described in the scenario. Understanding the various types of murmurs and being able to differentiate between them is crucial for healthcare providers working in obstetric settings. It helps in providing accurate assessments, appropriate interventions, and ensuring the well-being of both the pregnant woman and the fetus. Being able to identify benign conditions like mammary souffle can prevent unnecessary concern or intervention.
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: In this scenario, the correct response is option D: No correct response provided. This is because the midline linear protrusion noticed by the nurse is likely a normal finding known as diastasis recti, which is the separation of the rectus abdominis muscles along the linea alba. This is a common occurrence during pregnancy due to the stretching of the abdominal muscles to accommodate the growing uterus. Option A is incorrect because diastasis recti is a benign condition that does not typically require documentation unless it is severe or causing discomfort. Option B is incorrect as diastasis recti does not usually require surgical repair unless it is causing significant issues postpartum. Option C is incorrect as the protrusion is more likely due to diastasis recti rather than a hernia caused by increased abdominal pressure. From an educational standpoint, it is important for healthcare providers, especially nurses, to be knowledgeable about common physiological changes that occur during pregnancy. Understanding diastasis recti and differentiating it from more serious conditions like hernias is crucial for accurate assessment and appropriate patient education. By recognizing normal variations, nurses can provide reassurance to pregnant women and help them differentiate between expected changes and potential complications.
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: In this scenario, the correct answer is option D, which is to use ultrasound to verify cardiac activity. This is the most appropriate action to take when fetal heart tones are not heard at 22 weeks of pregnancy. Using ultrasound allows for a direct visualization of the fetus's heart activity, providing a more accurate assessment of the baby's well-being. Option A is incorrect because waiting 10 minutes and trying again without taking further action could delay necessary intervention if there is a serious issue with the fetus. Option B is incorrect as relying solely on the mother's perception of fetal movement may not provide a reliable indication of fetal well-being. Option C is also incorrect as simply waiting and trying again does not address the underlying reason for the inability to hear the fetal heart tones. From an educational standpoint, understanding the importance of utilizing technology like ultrasound in assessing fetal well-being is crucial for healthcare professionals caring for pregnant women. This question reinforces the significance of prompt and accurate assessment in detecting potential complications in early pregnancy, highlighting the need for appropriate interventions to ensure the best outcomes for both the mother and the baby.
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.