ATI RN
Promoting Client Comfort During Labor and Delivery Questions
Question 1 of 4
Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?
Correct Answer: B
Rationale: The correct answer is B: Symmetry of facial movements. Bruising over the cheeks can indicate potential nerve damage from the forceps birth. Assessing facial movements helps determine if there is any nerve injury affecting facial muscles. Presence of newborn reflexes (A) is important but not directly related to facial nerve injury. Caput and molding of the head (C) are more related to the birthing process and not specific to facial nerve assessment. Anterior and posterior fontanels (D) are important for assessing fontanelle closure but not specific to facial nerve evaluation.
Question 2 of 4
The labor nurse is developing a plan of care for a patient admitted in active labor with
Correct Answer: A
Rationale: The correct answer is A: On admission, vital signs were as follows: maternal heart rate (HR) 92 bpm; fetal rate (FHR) baseline, 150 to 160 bpm; blood pressure, 124/76 mm Hg; temperature 37.2° C (99° F). The priority nursing action for this patient is to assess the vital signs. The maternal heart rate, fetal heart rate, blood pressure, and temperature are crucial indicators of the patient's and the fetus's well-being during labor. Monitoring these vital signs helps the nurse detect any abnormalities or signs of distress promptly, allowing for timely intervention. Choice B, fetal acoustic stimulation, is not the priority at this stage as there are no indications in the question stem that suggest the need for this intervention. Choice C, assessing temperature every 2 hours, is not the priority as the patient's temperature is within normal range on admission. Choice D, changing absorption pads under her hips every 2 hours,
Question 3 of 4
When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Monitor and record vital signs frequently during the course of labor. This is essential to ensure the patient's physiological stability and detect any deviations that may indicate complications. Checking the DTR (Choice A) is not relevant for low-risk patients in labor. Documenting the FHR pattern (Choice C) is important, but not as crucial as monitoring vital signs. Indicating maternal position changes on the EFM tracing (Choice D) is beneficial but not a priority assessment for low-risk patients. Vital sign monitoring is the most critical assessment for ensuring the well-being of the patient in labor.
Question 4 of 4
The nurse is caring for a patient in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Soft boggy uterus. In the fourth stage of labor, the uterus should be firm and well-contracted to prevent postpartum hemorrhage. A soft, boggy uterus indicates uterine atony, a potential complication that can lead to excessive bleeding. B: Maternal temperature of 37.2°C (99F) is within normal range and not indicative of a complication. C: High uterine fundus displaced to the right could indicate a full bladder or uterine displacement, but it is not a direct sign of a complication in the fourth stage of labor. D: Intense vaginal pain unrelieved by analgesics may be due to various reasons but is not a typical complication in the fourth stage of labor.