ATI RN
Maternal Monitoring Questions
Question 1 of 5
The nurse who will care for a patient in labor receives a report and is told that the patient's status is as follows: 4 cm, 50%, and +1 station. What should be the nurse's interpretation of this information?
Correct Answer: C
Rationale: The correct interpretation is C because in labor progress, cervical dilation (4 cm) refers to how much the cervix has opened, effacement (50%) indicates the thinning of the cervix, and station (+1) describes the descent of the baby's head in relation to the ischial spines. Therefore, the nurse should understand that the cervix is dilated 4 cm, effaced 50%, and the baby's head is 1 cm below the ischial spines, which is indicative of progressing labor. Choice A is incorrect because it incorrectly describes the station as being 1 cm below the ischial spines instead of above. Choice B is incorrect as it inaccurately states that the cervix is effaced to 50% rather than dilated. Choice D is incorrect because it states that the cervix is effaced 4 cm, which is not a correct representation of effacement.
Question 2 of 5
Which of the following is the most accurate description of fetal station during labor?
Correct Answer: B
Rationale: The correct answer is B: The level of the presenting part in relation to the ischial spines. Fetal station refers to the position of the baby's head in the mother's pelvis during labor. It is measured in centimeters above or below the ischial spines. This measurement helps determine the progress of labor and the descent of the baby through the birth canal. Choices A, C, and D do not accurately describe fetal station and are therefore incorrect. Choice A refers to the cervical length, choice C refers to fetal position, and choice D refers to cervical dilation, which are not related to fetal station.
Question 3 of 5
A 38-week pregnant woman presents to the labor and delivery unit with regular contractions. The cervix is 3 cm dilated and 80% effaced. What is the next appropriate nursing action?
Correct Answer: D
Rationale: The correct answer is D: Continue to monitor contractions and fetal heart rate. At 3 cm dilated and 80% effaced, the woman is likely in early labor. Continuous monitoring is crucial to assess labor progression and fetal well-being. Vaginal exam (A) can increase infection risk. Preparing for delivery (B) is premature. Administering epidural (C) is based on pain management, not current labor stage. Monitoring contractions and fetal heart rate ensures timely intervention if needed.
Question 4 of 5
A woman in labor who is receiving oxytocin starts to experience uterine hyperstimulation. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Stop the oxytocin infusion. Uterine hyperstimulation can lead to fetal distress and compromise maternal and fetal well-being. Stopping the oxytocin infusion is the first step to prevent further complications. Administering a tocolytic agent (B) is not the initial action for uterine hyperstimulation. Increasing the oxytocin infusion rate (C) would exacerbate the hyperstimulation. Positioning the patient on her left side (D) can help improve blood flow but is not the priority in this situation.
Question 5 of 5
A patient in labor is requesting pain relief. What is the most appropriate intervention for a patient in the latent phase of labor?
Correct Answer: B
Rationale: The correct answer is B: Provide non-pharmacological pain relief methods. In the latent phase of labor, the cervix is dilated up to 6 cm and the contractions are typically mild to moderate. Non-pharmacological methods like massage, breathing techniques, warm showers, and position changes are most appropriate as they help the patient relax and cope with the pain without interfering with the progress of labor. Administering an epidural block (A) is not recommended in the latent phase as it can slow down labor. Administering narcotic analgesics (C) can affect the baby and may not provide adequate pain relief. Encouraging the patient to push (D) is not appropriate in the latent phase as it can lead to exhaustion and may not be effective until the cervix is fully dilated.