ATI RN
Maternal Monitoring Questions
Question 1 of 5
Which of the following interventions is most appropriate for a postpartum person who has difficulty initiating breastfeeding?
Correct Answer: B
Rationale: The correct answer is B: administer pain relief. Pain can be a common barrier to initiating breastfeeding. By providing pain relief, the postpartum person may feel more comfortable and be better able to initiate breastfeeding. Hand expression (A) may not address the underlying issue of pain. Offering additional support and education (C) may be beneficial but addressing pain is more urgent. Administering a breast pump (D) is not necessary at this stage unless there are specific indications.
Question 2 of 5
A nurse is caring for a postpartum person who is at risk for deep vein thrombosis (DVT). What is the most appropriate nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Apply compression stockings. This intervention is appropriate for a postpartum person at risk for DVT as it helps promote circulation and prevent blood clots by applying pressure to the legs. Compression stockings are a safe and non-invasive method to reduce the risk of DVT. Encouraging ambulation (choice A) is important but may not be feasible immediately postpartum. Administering low-molecular-weight heparin (choice C) would require a prescription and may not be the first-line intervention. Monitoring for signs of edema (choice D) is important but does not directly address the prevention of DVT like compression stockings do.
Question 3 of 5
A nurse is assisting with a vaginal birth and notices a prolapsed umbilical cord. What is the immediate nursing action?
Correct Answer: A
Rationale: The correct immediate nursing action for a prolapsed umbilical cord is to administer oxygen via mask (Choice A). This is crucial to ensure adequate oxygenation to the fetus as the prolapsed cord can compress and compromise blood flow. Administering oxygen helps maintain fetal oxygenation until emergency measures can be taken. Placing the person in the knee-chest position (Choice B) is contraindicated as it can further compress the cord. Repositioning the laboring person (Choice C) may not effectively relieve pressure on the cord. While preparing for an emergency delivery (Choice D) is important, administering oxygen is the priority to ensure fetal well-being.
Question 4 of 5
What is the most common complication of a cesarean birth?
Correct Answer: A
Rationale: The correct answer is A: infection. Infection is the most common complication of a cesarean birth due to the incision made during the procedure, which can introduce bacteria. Infections can lead to various complications if not treated promptly. Hemorrhage (B) can occur but is less common than infection. Urinary retention (C) and scar tissue (D) are potential complications of cesarean birth but are not as common as infection.
Question 5 of 5
A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?
Correct Answer: D
Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.