Review ATI Maternity quiz 2

Exam Review

ATI Maternity quiz 2

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy

We are excited to announce the release of a NEW VERSION OF THE SYSTEM! To benefit from the latest features, improvements, and component updates, please switch to the new system as soon as possible.

Visit Latest Version

Total Questions : 37

Showing 10 questions, Sign in for more

Question 1:

When the mother's membranes rupture during active labor, the fetal heart rate should be observed for the occurrence of which periodic pattern?

A. Increase in baseline variability. B. Non-periodic accelerations. C. Early decelerations. D. Variable decelerations.

Answer and Explanation

Choice A:

An increase in baseline variability is generally considered a reassuring sign of fetal well-being, indicating a responsive central nervous system and adequate oxygenation. While important to monitor, it is not a specific periodic pattern to observe immediately following membrane rupture due to potential cord compression. Normal baseline variability ranges from 6 to 25 beats per minute.

Choice B:

Non-periodic accelerations are abrupt increases in fetal heart rate above the baseline, typically lasting less than 30 seconds. They are usually a reassuring sign, often occurring with fetal movement or stimulation. While their presence is noted, they are not the primary periodic pattern to observe immediately after membrane rupture for potential complications.

Choice C:

Early decelerations are gradual decreases in fetal heart rate that mirror the uterine contractions. They are thought to be caused by fetal head compression and are generally considered benign. While their presence is documented, they are not the most concerning pattern immediately after membrane rupture, which raises the risk of cord issues.

Choice D:

Variable decelerations are abrupt decreases in fetal heart rate that are variable in timing and shape in relation to uterine contractions. They are often caused by umbilical cord compression, which is a significant risk factor immediately following the rupture of membranes, as the fluid cushion around the cord is reduced. Prompt identification is crucial for intervention.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 2:

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes.
What is the nurse's highest priority?

A. Assessing the woman's vital signs. B. Calling the woman's primary health care provider. C. Massaging the woman's fundus. D. Beginning an intravenous (IV) infusion of Ringer's lactate solution.

Answer and Explanation

Choice A:

Assessing vital signs is important in evaluating a postpartum hemorrhage, but it is not the immediate priority. Significant blood loss can occur before changes in vital signs become apparent due to compensatory mechanisms in the body. Addressing the source of bleeding is the initial critical step.

Choice B:

Calling the primary health care provider is a necessary step, but it should occur after the nurse has taken immediate action to address the likely cause of the excessive bleeding. Direct intervention to control the hemorrhage takes precedence over notification.

Choice C:

Massaging the fundus is the highest priority because uterine atony, a soft and boggy uterus that does not contract effectively, is the most common cause of early postpartum hemorrhage. Stimulating uterine contraction by massage can help to compress the blood vessels at the placental site and reduce bleeding.

Choice D:

Initiating an intravenous (IV) infusion of Ringer's lactate solution is important for volume replacement if bleeding is significant, but it is not the immediate first action. Addressing the uterine atony through fundal massage should be done first to try and control the bleeding.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 3:

The nurse assessing a postpartum client's fundus finds it firm, 2 centimeters above the umbilicus and displaced to the right.
What is the most appropriate nursing intervention at this time?

A. Have the client void and reassess the fundus. B. Start a pad count. C. Massage the fundus until firm. D. Notify the healthcare provider.

Answer and Explanation

Choice A:

A firm fundus displaced to the right and above the umbilicus often indicates a full bladder. The bladder, when distended, can push the uterus out of its midline position and interfere with its ability to contract effectively, potentially leading to increased bleeding. Having the client void will relieve the pressure on the uterus, allowing it to return to its midline position and remain firm.

Choice B:

Starting a pad count is a useful way to quantify the amount of lochia, but it does not address the immediate issue of the displaced fundus and potential bladder distention. It would be a subsequent step to monitor the bleeding after addressing the fundal position.

Choice C:

While fundal massage is appropriate for a soft or boggy uterus, the assessment indicates the fundus is already firm. Massaging a firm uterus is not the priority and will not address the displacement caused by a likely full bladder.

Choice D:

Notifying the healthcare provider is necessary if the fundus remains displaced and elevated after the client voids, as this could indicate other complications. However, the initial action should be to address the most likely cause, which is bladder distention.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 4:

A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.
As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

A. Pain in the abdomen, shoulder, or back. B. Respiratory depression, hypotension, absent tendon reflexes. C. Severe lower back pain, leg cramps, sweating. D. Low potassium or elevated glucose, tachycardia, chest pain.

Answer and Explanation

Choice A:

Pain in the abdomen, shoulder, or back can be associated with pre-term labor or other pregnancy complications and should be assessed. However, respiratory depression, hypotension, and absent tendon reflexes are more indicative of magnesium sulfate toxicity and pose an immediate threat to the client's safety.

Choice B:

Magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and tocolysis in pre-term labor. Respiratory depression (respiratory rate less than 12 breaths per minute), hypotension (systolic blood pressure less than 90 mmHg or a significant drop from baseline), and absent deep tendon reflexes are signs of magnesium toxicity and require immediate intervention to prevent serious adverse effects.

Choice C:

Severe lower back pain, leg cramps, and sweating can be symptoms of pre-term labor or other musculoskeletal issues during pregnancy. While important to assess and manage, they do not represent the same immediate life-threatening risk as magnesium toxicity.

Choice D:

Low potassium or elevated glucose levels, tachycardia, and chest pain are not typical side effects of magnesium sulfate. These findings could indicate other underlying medical conditions that need investigation, but they are not the priority assessment related to magnesium sulfate administration compared to signs of toxicity. Normal potassium range is 3.5-5.0 mEq/L, normal fasting glucose is 70-100 mg/dL.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 5:

A nurse is caring for a client who is 1 hour postpartum following a vaginal birth.
The client has saturated a perineal pad within 10 minutes.
Which of the following actions should the nurse take first?

A. Prepare to administer a prescribed oxytocic preparation. B. Assess the client's blood pressure. C. Assess the bladder for distention. D. Massage the client's fundus.

Answer and Explanation

Choice A:

Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.

Choice B:

Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.

Choice C:

Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.

Choice D:

Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 6:

The nurse is managing care of a primigravida at full term who is in the active phase of labor.
What should be included in developing the plan of care for this client?

A. Supine positioning on back if it is comfortable. B. Anesthesia/pain level assessment every 30 minutes. C. Vaginal bleeding and fundus of the uterus after delivery of the placenta. D. Oxygen saturation monitoring every half hour.

Answer and Explanation

Choice A:

Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.

Choice B:

Assessing anesthesia or pain level every 30 minutes is crucial in the active phase of labor to evaluate the effectiveness of pain management interventions and the client's comfort. This frequent monitoring allows for timely adjustments to the pain management plan based on the client's subjective experience and physiological responses.

Choice C:

While assessing vaginal bleeding and the fundus is important in the postpartum period to monitor for uterine involution and hemorrhage, it is not the priority during the active phase of labor. The focus during active labor is on maternal and fetal well-being during the labor process itself.

Choice D:

Continuous or intermittent oxygen saturation monitoring may be indicated based on the client's condition and fetal heart rate patterns, but it is not a routine assessment every half hour for all clients in active labor. It is typically reserved for situations of suspected maternal hypoxemia or fetal distress.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 7:

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

A. Spontaneous rupture of membranes. B. Fetal head compression. C. Umbilical cord compression. D. Utero-placental insufficiency.

Answer and Explanation

Choice A:

Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.

Choice B:

Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.

Choice C:

Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.

Choice D:

Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 8:

The clinic nurse is caring for a client at 31 weeks gestation who is scheduled for induction of labor at 42 weeks gestation.
Which teaching is a priority for this client?

A. Methods of labor induction. B. Benefits of breastfeeding. C. Signs of labor. D. Monitoring of fetal movement.

Answer and Explanation

Choice A:

While understanding methods of labor induction is important if the pregnancy progresses to 42 weeks, it is not the priority teaching at 31 weeks gestation. The immediate focus should be on recognizing potential complications that could arise before the scheduled induction.

Choice B:

The benefits of breastfeeding are important for all pregnant women but are not the priority teaching for a client at 31 weeks who is not yet in labor. Information about breastfeeding can be provided later in the pregnancy.

Choice C:

Teaching the signs of labor is important as the client approaches term, but at 31 weeks, the priority is to educate the client on recognizing potential warning signs that require immediate attention, such as decreased fetal movement.

Choice D:

Monitoring fetal movement is a crucial teaching point at 31 weeks gestation. A decrease in fetal movement can be an early indicator of fetal compromise and requires prompt evaluation. Instructing the client on how to perform kick counts and when to report changes is a priority for ensuring fetal well-being before the scheduled induction.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 9:

The obstetric nurse is preparing the client for an emergency cesarean birth, with no time to administer spinal anesthesia; general anesthesia will be used.
What is the greatest risk of administering general anesthesia to the client during postpartum?

A. Risk for newborn infection. B. Risk for DVT. C. Postpartum bleeding. D. Risk for infection.

Answer and Explanation

Choice A:

The risk for newborn infection is primarily associated with prolonged rupture of membranes or maternal infection during labor, not directly with the administration of general anesthesia during a cesarean birth.

Choice B:

While the postpartum period is a time of increased risk for DVT due to hormonal changes and decreased mobility, general anesthesia itself does not significantly increase this risk compared to regional anesthesia. Surgical procedures in general increase DVT risk.

Choice C:

General anesthesia can lead to uterine atony, a condition where the uterus fails to contract adequately after delivery. This lack of contraction can result in postpartum hemorrhage, making postpartum bleeding the greatest risk associated with general anesthesia in this scenario.

Choice D:

The risk for infection is primarily associated with the surgical incision and the postpartum period in general, not specifically with the type of anesthesia used during the cesarean birth.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 10:

A nurse on a labor unit is admitting a client who reports painful contractions.
The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes.
The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 82/54 mm Hg. Which of the following is the priority action for the nurse to take?

A. Ask the client if she needs pain medication. B. Position the client with one hip elevated. C. Have the client void. D. Notify the provider of the findings.

Answer and Explanation

Choice A:

While addressing the client's pain is important, the priority action should be to assess the underlying cause of the concerning vital signs before offering pain medication.

Choice B:

Positioning the client with one hip elevated is a measure used to relieve potential vena cava compression, but the low blood pressure warrants immediate attention and further evaluation before implementing this intervention.

Choice C:

Having the client void may be a helpful intervention in some labor situations, but the combination of a low maternal blood pressure and a high maternal heart rate requires immediate notification of the provider.

Choice D:

The client's low blood pressure (82/54 mm Hg) and elevated maternal heart rate (128/min) in the presence of contractions with a duration of 1 minute and a frequency of 3 minutes are concerning findings that warrant immediate notification of the provider for further evaluation and management. These vital signs could indicate maternal hypovolemia, dehydration, or other complications. .

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Sign Up or Login to view all the 37 Questions on this Exam

Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.

Exam Review

ATI Maternity quiz 2 Share this Share This Link Share on social media Facebook Messager WhatsApp Share URL Copy Close

Total Questions : 37

Sign Up or Login to view all the 37 Questions on this Exam

ATI Maternity quiz 2

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy