ATI RN
Promoting patient comfort during labor and birth questions quizlet Questions
Question 1 of 5
Which intervention is an essential part of nursing care for a laboring patient?
Correct Answer: A
Rationale: The correct answer is A because helping the woman manage the pain is essential in nursing care for a laboring patient to ensure her comfort and well-being during labor. This intervention includes providing pain relief measures, such as positioning, massage, breathing techniques, and administering pain medication if needed. The focus is on supporting the woman's coping mechanisms and enhancing her overall birthing experience. Choice B is incorrect because eliminating pain completely is not always possible or recommended in labor, as some pain is a natural part of the process. Choice C is incorrect as comfort with the predictable nature of care is not as crucial as providing active pain management. Choice D is incorrect because sharing personal experiences may not be relevant or helpful to the laboring patient and may not address her specific needs during labor.
Question 2 of 5
The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is most appropriate at this time?
Correct Answer: C
Rationale: The correct answer is C: Report the fetal heart rate to the physician or nurse-midwife immediately. A fetal heart rate of 152 bpm is within the normal range for a fetus, but it is essential to communicate any findings to the healthcare provider for further assessment and monitoring. This step ensures the safety and well-being of both the mother and the fetus by allowing the healthcare provider to determine if any additional actions are necessary. Incorrect choices: A: Inform the mother that the fetal heart rate is normal - While the heart rate may be normal, it is crucial to involve the healthcare provider for proper evaluation. B: Reassess the fetal heart rate in 5 minutes because the rate is too high - 152 bpm is not considered too high, and immediate reporting to the healthcare provider is necessary. D: Suggest to the mother that she is going to have a boy because the heart rate is fast - Fetal heart rate is not a reliable indicator of the baby's gender, and this
Question 3 of 5
Which nursing assessment indicates that a patient who is in the second stage of labor is almost ready to give birth?
Correct Answer: B
Rationale: The correct answer is B because the vulva bulging and encircling the fetal head is a sign that the baby is descending through the birth canal, indicating the patient is almost ready to give birth. This is known as crowning. A: Bloody mucous discharge increasing is a sign of early labor, not necessarily indicating imminent birth. C: Feeling the fetal head at 0 station means the baby is engaged in the pelvis, but it does not indicate the exact timing of birth. D: Membranes rupturing during a contraction can happen at any stage of labor and do not necessarily signify imminent birth.
Question 4 of 5
If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to
Correct Answer: A
Rationale: The correct answer is A: massage the fundus. After childbirth, a soft fundus indicates uterine atony, which can lead to postpartum hemorrhage. Massaging the fundus helps stimulate contractions and reduce bleeding, promoting uterine tone. This intervention is crucial in preventing complications. Taking blood pressure (B) is important but not the priority in this situation. Increasing blood supply to the hands and feet (C) is not relevant to addressing uterine atony. Notifying the physician or nurse-midwife (D) can be done after initiating immediate intervention to manage the soft fundus.
Question 5 of 5
The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Document this evidence of normal early maternal-infant attachment behavior. This is the correct action because the mother's behavior of touching her infant with her fingertips and talking to him softly in high-pitched tones is indicative of normal maternal-infant attachment. This behavior shows that the mother is engaging with her infant in a positive and nurturing way, which is crucial for bonding and attachment. It is important for the nurse to document this behavior as it reflects a healthy interaction between the mother and her newborn. Other choices are incorrect: A: Request a social service consult for psychosocial support - This choice is not necessary as the mother's behavior indicates normal attachment and does not suggest a need for psychosocial support at this time. B: Observe for other signs that the mother may not be accepting of the infant - This choice is unnecessary as the mother's current behavior demonstrates acceptance and attachment towards her infant. D: Determine whether the mother is too fatigued to interact normally