ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 5
Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient?
Correct Answer: D
Rationale: The correct answer is D. Saturation of two perineal pads in 4 hours is an indication of hemorrhage postpartum. This is because excessive bleeding after delivery can lead to soaking through pads quickly. A: Elevated pulse rate can be a sign of shock but not specific to hemorrhage. B: Elevated blood pressure is not a typical sign of hemorrhage. C: A firm fundus at the midline is a normal finding postpartum and not indicative of hemorrhage.
Question 2 of 5
A woman who is gravida 3, para 2 enters the intrapartum unit. The most important nursing assessments include
Correct Answer: B
Rationale: The correct answer is B because fetal heart rate, maternal vital signs, and the woman's nearness to birth are crucial assessments in the intrapartum period. Fetal heart rate indicates fetal well-being, maternal vital signs reflect maternal status, and assessing the nearness to birth helps in determining the stage of labor and necessary interventions. A is incorrect because while contraction pattern and discomfort are important, pregnancy history is not as immediate a concern in the intrapartum period. C is incorrect as last food intake and cultural practices are not the most critical assessments during labor. D is incorrect because while identification of ruptured membranes is important, the woman's gravida and para are less immediate concerns compared to fetal heart rate and maternal vital signs.
Question 3 of 5
Which clinical finding would be an indication to the nurse that the fetus may be compromised?
Correct Answer: D
Rationale: The correct answer is D. Meconium-stained amniotic fluid indicates fetal distress due to possible hypoxia. Meconium in the fluid can lead to meconium aspiration syndrome, a serious condition. The other choices are incorrect because active fetal movements (A) and a fetal heart rate in the 140s (B) are normal signs of fetal well-being. Contractions lasting 90 seconds (C) could indicate labor progress but do not necessarily indicate fetal compromise.
Question 4 of 5
During labor a vaginal examination should be performed only when necessary because of the risk of
Correct Answer: A
Rationale: Step 1: Vaginal examination during labor can introduce bacteria, leading to infection. Step 2: Infections can be harmful to both the mother and the baby. Step 3: Minimizing unnecessary vaginal exams reduces the risk of infection. Summary: Choice A is correct because infection poses serious risks. Choices B, C, and D are incorrect as they do not directly address the primary risk associated with vaginal examinations during labor.
Question 5 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.