Antenatal Rationale Worksheet - Answer Key

Student Name: 1. A nurse in a prenatal clinic is caring for a client who is at 38 weeks gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress, and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? A. B. C. D. Fetal Lung Maturity Location of the placenta Viability of the fetus The Biparietal diameter Rationale: The client is in 3rd trimester; Painless, spontaneous vaginal bleeding may indicate Placenta Previa. Ultrasound is used to locate the placenta Source: ATII 11.0. chapter 7 page 44 2. A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which interpretation of these findings by the nurse is correct? A. A negative test B. A non-reactive test C. A positive test D. A reactive test Rationale: Doesn’t show 2 quality accelerations in a 20 minute window. Source: ATI 11.0 chapter 6 pg 33 3. A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks gestation. The nurse provides which explanation about this test to the client? A. This test assesses fetal lung maturity B. It assesses various markers of fetal well-being. C. This test identifies an Rh incompatibility between the mother and fetus. D. It is a screening test for spinal defects in the fetus. Rationale: Occurs between 15-22 weeks. To rule out down syndrome and neural tube defects. Source: ATI 11.0 chapter 4 pg22 4. A nurse in a prenatal clinic is caring for a client who is at 38 weeks gestation and undergoing a contraction stress test. The test results are negative. Which interpretation of this finding should the nurse make? A. There is evidence of cervical incompetence B. There is no evidence of utero-placental insufficiency C. There is no evidence of two or more accelerations in the fetal heart rate in 20 minutes D. There are less than 3 uterine contractions in a 10-minute period. Rationale: negative test results means no late deceleration of the FHR Source:ATI 11.0 chp 6; page 34 5. A nurse is providing teaching to a client who is at 30 weeks gestation and is to have a nonstress test (NST). Which statement by the client indicates a need for further teaching? A. “I will need to lie on my back during the test.” B. “My baby’s heart rate will be monitored during the test.” C. “I should schedule the test when my baby is usually active.” D. “It will take at least 20 to 30 minutes to complete the test.” Rationale: client should be in reclining chair, semi fowler or left lateral position. Source:ATI 11.0 chp 6 pg 33 6. The nurse is providing education regarding exercise and pregnancy. Which response by the client indicates an understanding of the teaching? A. “Walking and stretching exercises will help with overall body conditioning.” B. “I should start a new exercise routine to keep in shape.” C. “I will perform non-weight bearing exercises.” D. “Exercise will help me lose weight during the pregnancy.” Rationale: walking and stretching exercises can help overall pregnancy such as alleviate back pain, Source: ATI 11.0 chp 4 page 22 7. A client states, "I think I might be pregnant. My period is late, and I've been feeling really nauseous." Which would be the best response by the nurse? A. “These are presumptive signs of pregnancy; you could be pregnant.” B. “That’s great! I am so happy for you!” C. “These are positive signs of pregnancy; you are absolutely pregnant!” D. “You should schedule an appointment to make sure you do not have an ectopic pregnancy.” Rationale: these are Presumptive signs: “subjective” These signs also might result of physiological factors such as infection, stress, peristalsis. Source: ATI 11.0 chp 3. Pg 17 8. The nurse is teaching a group of students about the different types of tests performed at different stages of pregnancy. Which statement would the nurse include in the teaching? Select all that apply A. “A non-stress test is a screening tool that uses the fetal heart rate patterns and accelerations as an indicator of fetal well-being.” B. “Maternal serum Alpha fetoprotein is a screening test that screens for levels of AFP in the maternal blood to detect certain developmental defects in the fetus, such as neural tube defects.” C. “An amniocentesis is an ultrasound assessment of fetal status with an NST. It utilizes ultrasound with EFM to assess five variables.” D. “BPP (Biophysical Profile) is a diagnostic procedure where a needle is inserted through the abdominal wall into the uterine cavity to obtain amniotic fluid and commonly performed for genetic testing.” E. “An amniocentesis is necessary to evaluate the uterus. It is done during the first half of the pregnancy.” Rationale: Amniocentesis is performed uses ultrasound, but not with NST or to assess five variables. This is BPP BPP does not use an needle for the procedure. It uses NST and Five variables. A needle is used for Amniocentesis Amniocentesis isn’t to evaluate the uterus and it performed in 2nd half; after 14 weeks Source: ATI 11.0 chp 6. Pg35 9. A woman who is planning to get pregnant started 0.4 mg/day of folic acid. She visited her primary physician, and the dose was later increased to 0.8 mg/day because she had an infant with neural tube defect (NTD). The stock volume for folic acid is 0.4 mg. The nurse is expected to instruct the woman to take __2___ tablets per day? Fill in the blank. Do not include units. Show your Math: current dose is 0.4mg/day. Is increased to 0.8mg/day 0.4 x2 = 0.8 dose of 0.8mg/day therefore she will need to 2 tablets in order to equal the new prescribed 10. A nurse is performing Leopold's maneuver on a woman who is 34 weeks gestation prior to listening to fetal heart tones. A smooth firm surface is felt on the maternal right side. A firm, round, presenting part is located in the lower uterine segment. Where would the nurse hear fetal heart tones best? A. B. C. D. Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant Rationale: Location of the fetus’s back to assess for fetal heart tones. The left lower quadrant would be the best location to heart fetal heart beat Source:ATI 11.0 chp 11 pg 77