ATI RN
Maternal Monitoring Questions
Question 1 of 5
Which of the following is the most accurate description of fetal station during labor?
Correct Answer: B
Rationale: The correct answer is B: The level of the presenting part in relation to the ischial spines. Fetal station refers to the position of the baby's head in the mother's pelvis during labor. It is measured in centimeters above or below the ischial spines. This measurement helps determine the progress of labor and the descent of the baby through the birth canal. Choices A, C, and D do not accurately describe fetal station and are therefore incorrect. Choice A refers to the cervical length, choice C refers to fetal position, and choice D refers to cervical dilation, which are not related to fetal station.
Question 2 of 5
A woman in labor who is receiving oxytocin starts to experience uterine hyperstimulation. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Stop the oxytocin infusion. Uterine hyperstimulation can lead to fetal distress and compromise maternal and fetal well-being. Stopping the oxytocin infusion is the first step to prevent further complications. Administering a tocolytic agent (B) is not the initial action for uterine hyperstimulation. Increasing the oxytocin infusion rate (C) would exacerbate the hyperstimulation. Positioning the patient on her left side (D) can help improve blood flow but is not the priority in this situation.
Question 3 of 5
A patient in labor is requesting pain relief. What is the most appropriate intervention for a patient in the latent phase of labor?
Correct Answer: B
Rationale: The correct answer is B: Provide non-pharmacological pain relief methods. In the latent phase of labor, the cervix is dilated up to 6 cm and the contractions are typically mild to moderate. Non-pharmacological methods like massage, breathing techniques, warm showers, and position changes are most appropriate as they help the patient relax and cope with the pain without interfering with the progress of labor. Administering an epidural block (A) is not recommended in the latent phase as it can slow down labor. Administering narcotic analgesics (C) can affect the baby and may not provide adequate pain relief. Encouraging the patient to push (D) is not appropriate in the latent phase as it can lead to exhaustion and may not be effective until the cervix is fully dilated.
Question 4 of 5
A 35-week pregnant woman presents with ruptured membranes. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Check for cord prolapse. This is the priority intervention because with ruptured membranes, there is a risk of umbilical cord prolapse, which can lead to fetal compromise. Checking for cord prolapse allows for quick identification and immediate intervention to prevent potential harm to the baby. Choice B is incorrect as monitoring for fetal distress is important but not the immediate priority when cord prolapse is a concern. Choice C, administering antibiotics, may be necessary but does not address the immediate risk of cord prolapse. Choice D, performing a vaginal exam, can increase the risk of infection and should be avoided until cord prolapse is ruled out.
Question 5 of 5
A woman in labor is experiencing severe perineal pressure and the urge to push. What should the nurse assess next?
Correct Answer: A
Rationale: The correct answer is A: Cervical dilation. Assessing cervical dilation is crucial as it indicates the progress of labor and readiness for pushing. The nurse needs to determine if the woman is fully dilated to guide the timing of pushing. B: Fetal position is important but not the immediate priority when the woman is experiencing the urge to push. C: Fetal heart rate should be continually monitored during labor but is not the next assessment when the woman has the urge to push. D: Maternal blood pressure is important but not the immediate concern when the woman is ready to push.