ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
The nurse thoroughly dries the infant immediately after birth primarily to
Correct Answer: A
Rationale: The correct answer is A because drying the infant helps reduce heat loss through evaporation, preventing hypothermia. Wet skin can lead to rapid heat loss. This is critical for newborns who are at risk of temperature instability. Choice B is incorrect because drying the infant is not primarily done to stimulate crying and lung expansion. Choice C is incorrect because drying does not increase blood supply to the hands and feet. Choice D is incorrect because maternal blood is typically cleared from the infant's skin through other means, not primarily by drying.
Question 2 of 5
A nursing priority during admission of a laboring patient who has not had prenatal care is
Correct Answer: B
Rationale: The correct answer is B: identifying labor risk factors. This is a priority because it helps in assessing potential complications and planning appropriate care. Obtaining admission labs (A) can be important but not the top priority. Discussing birth plan choices (C) can wait until after assessing risk factors. Explaining the importance of prenatal care (D) is not the immediate concern during labor admission. Identifying labor risk factors is crucial for ensuring the safety and well-being of both the mother and the baby.
Question 3 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 4 of 5
After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?
Correct Answer: D
Rationale: The correct answer is D. Edema and discoloration of the labia and perineum indicate the presence of a potential vaginal wall hematoma. This is because hematoma can cause swelling and bruising in the affected area. Bright red lochia and a firm fundus are more indicative of postpartum hemorrhage, not vaginal wall hematoma. Choices A and C are not directly related to the presence of a vaginal wall hematoma. Mild, intermittent perineal pain (Choice B) is non-specific and can be present in various postpartum conditions. Thus, option D is the most relevant indicator of a potential vaginal wall hematoma in this scenario.
Question 5 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.