ATI RN
Possible Complications in Early Pregnancy Questions
Question 1 of 5
When examining the face of a woman who is 28 weeks pregnant, the nurse notices the presence of a butterfly-shaped increase in pigmentation on the face. The proper term for this finding in the documentation is:
Correct Answer: B
Rationale: The correct answer is B because chloasma is the medical term for a butterfly-shaped increase in pigmentation on the face. While it is also known as the mask of pregnancy, the nurse should use the correct medical term in documentation. Striae refers to stretch marks, and linea nigra is a hyperpigmented line on the abdomen.
Question 2 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 3 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 4 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.
Question 5 of 5
What is the recommended frequency for performing Kegel exercises?
Correct Answer: C
Rationale: Kegel exercises are recommended to strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum. Performing Kegel exercises 50 to 100 times a day is the recommended frequency to see improvements in muscle strength and control over time. This frequent repetition helps to effectively target and strengthen the pelvic floor muscles, leading to better bladder control, improved sexual function, and reduced risk of pelvic organ prolapse. Option A is incorrect because the purpose of Kegel exercises is not specifically to keep the uterus strong during pregnancy. While strengthening the pelvic floor muscles can indirectly support the uterus during pregnancy, the primary goal of Kegel exercises is to improve pelvic floor muscle strength and function. Option B is incorrect because simply performing Kegel exercises twice a day may not provide enough repetitions to effectively strengthen the pelvic floor muscles. The recommended frequency of 50 to 100 repetitions a day is necessary to see significant improvements in muscle strength and control. Option D is incorrect because it describes the technique of performing Kegel exercises rather than the recommended frequency. While the described technique is important for performing Kegel exercises correctly, the frequency of 50 to 100 repetitions a day is more crucial for achieving the desired strengthening and functional benefits of Kegel exercises.