ATI Maternal newborn assessment A Questions with complete solutions

ATI Maternal newborn assessment A Questions with complete solutions A nurse on the postpartum unit is caring for a pt. following a cesarean birth. Which of the following assessments is the nurse's priority? a. parent-child attachment b. amount of lochia c. patency of the IV catheter d. quality and quantity of urine b. amount of lochia when using the ABCs approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. the greatest risk to the client is bleeding and postpartum hemorrhage. a nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. the client is dilated to 8cm and reports back pain. which of the following actions should the nurse take? a. apply sacral counter pressure b. perform trancutaneous electrical nerve stimulation (TENS) c. initiate slow-paced breathing d. assist with biofeedback a. apply sacral counter pressure the nurse should apply sacral counter pressure to assist in relieving back labor pain related to fetal posterior position b. the nurse should perform TENS during the first stage of labor. c. the nurse should transition a client to pattern-paced breathing during this stage of labor. d. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor. a nurse is demonstrating to a client how to bathe her newborn. in which order should the nurse perform the following actions a. wipe the newborn's eyes from inner canthus outward b. wash the newborn's legs and feet c. wash the newborn's neck by lifting the newborn's chin d. cleanse the skin around the newborn's umbilical stump e. clean the newborn's diaper area a. wipe the newborn's eyes from inner canthus outward c. wash the newborn's neck by lifting the newborn's chin d. cleanse the skin around the newborn's umbilical stump b. wash the newborn's legs and feet e. clean the newborn's diaper area The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. a nurse is caring for a client and her partner who have experienced a fetal death. which of the following actions should the nurse take? a. take photos of the newborn to give to the parents b. tell the parents that they can consider organ donation c. encourage the parents to avoid allowing older children to visit them in the hospital d. explain to the parents the need to name the newborn a. take photos of the newborn to give to the parents the nurse should create a memory box that includes mementos of the newborn (ex: photos, ID bands, newborn hat and blanket) b. Organ donation can be considered if a newborn is delivered alive. c. The nurse should encourage the client to allow older children to come to the hospital as a beneficial part of the grieving process. d. The nurse should explain to the client that naming the baby can be helpful during the grieving process, but it is not a requirement. a nurse is caring for a client who is 36 weeks gestation and has a positive contraction stress test. the nurse should plan to prepare the clients for which of the following diagnostic tests? a. biophysical profile b. amniocentesis c. cordocentesis d. Kleihauer- Burke test a. biophysical profile a positive contraction stress test indicate further evaluation of the fetus is necessary. a biophysical profile will provide further evaluation with real-time ultrasound b. An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. c. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. d. The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization. a nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. which of the following laboratory results should the nurse report to the provider? a. hct 39% b. serum albumin 4.5 g/dL c. WBC 9,000/mm3 d. platelets 50,000/mm3 d. platelets 50,000/mm3 a platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. the nurse should report this result to the provider a. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. b. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. c. A WBC of 9,000/mm3 is within the expected reference range. a nurse is assessing a newborn who was born at 26 weeks gestation using the Ballard score. which of the following findings should the nurse expect? a. minimal arm recoil b. popliteal angle of 90 c. creases over the entire foot sole d. raised areolas with 3-4mm buds a. minimal arm recoil the nurse should expect a newborn that was born at 26 weeks to have decreased muscular tone or minimal arm recoil b. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. c. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. d. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks. a nurse is assessing a newborn following a circumcision. which of the following findings should the nurse identify as an early indication that the newborn is experiencing pain? a. decrease heart rate b. chin quivering c. pinpoint pupils d. slowed respirations b. chin quivering behavioral responses to a newborn's pain include facial expressions (ex: chin quivering, grimacing, furrowing of brow) a. The heart rate will increase when a newborn is experiencing pain. c. When experiencing pain, a newborn's pupils typically dilate. d. When experiencing pain, a newborn's respirations are typically rapid and shallow. a nurse is assessing the newborn of a client who took a SSRI during pregnancy. which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? a. large for gestational age b. hyperglycemia c. bradypnea d. vomiting d. vomiting expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. these manifestations typically last 2 days a. Low birth weight is an expected clinical manifestation of fetal exposure to SSRIs. b. Hypoglycemia is an expected clinical manifestation of fetal exposure to SSRIs. c. Tachypnea is an expected clinical manifestation of fetal exposure to SSRIs. a nurse is developing a plan of care for a newborn who is to undergo photo-therapy for hyperbilirubinemia. which of the following actions should the nurse include in the plan? a. feed the newborn 1 oz of water every 4 hours b. apply lotion to the newborn's skin 3 times per day c. remove all clothing form the newborn except the diaper d. discontinue therapy if the newborn develops a rash c. remove all clothing from the newborn except the diaper the nurse should remove all of the newborn's clothing except the diaper while under photo-therapy. maximum ski exposure to the ultraviolet light is needed to break down the excess bilirubin. a. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin or provide nutritional value. b. The nurse should not apply lotion or creams to a newborn who is undergoing phototherapy. Lotions and creams can absorb heat and lead to burns. d. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment. a nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. which of the following cultural practices should the nurse include in plan of care? a. protect head and feet from cold air b. bathe the client within 12 hours following delivery c. ambulate the patient within 24 hr following delivery d. offer the patient a glass of cold milk with her first meal a. protect head and feet from cold air protecting the client's head and feet from cold air should be included in the plan of care because it is traditional Hispanic practice during the postpartum period. b. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. c. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery. d. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth. a nurse is caring for a client who is at 38 weeks gestation. which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. determine progression of dilation and effacement b. perform the Leopold maneuver c. complete a sterile speculum exam d. prepare a nitrazine paper test b. perform the Leopold maneuver the nurse should perform Leopold maneuver to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer a. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. c. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. d. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring. a nurse is caring for a client who is in active labor and has no cervical changes in the last 4 hours. which of the following statements should the nurse make? a. "let me help you into a comfortable pushing position so you can begin bearing down" b. "I am going to call the doctor to get you a prescription for medication to ripen your cervix" c. " I will give you some IV pain medication to strengthen your contraction" d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor a. The nurse should not instruct the client to start bearing down until the second stage of labor. b. A cervical ripening agent is not used during the active stage of labor. c. Administering IV pain medication can decrease the intensity of uterine contractions. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? a. massage the client's fundus b. insert an indwelling urinary catheter c. administer oxygen at 10L/min d. elevate the client's right hip a. massage the client's fundus the greatest risk to the client is hemorrhage. therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions b. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. c. The nurse should administer oxygen at 10 L/min to enhance perfusion. However, this is not the next action the nurse should take. d. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take. a nurse is reviewing the medical record of a client who is one day postpartum. the client had a vaginal birth with a 4th degree perineal laceration. the nurse should contact the provider regarding which of the following prescriptions? a. docusate sodium 100mg PO TID b. sitz bath 2-3 times per day PRN pain c. bisacodyl rectal suppository daily PRN constipation d. ibuprofen 600mg PO Q 6hours PRN pain c. bisacodyl rectal suppository daily PRN constipation the nurse should NOT administer a rectal suppository or enema to a client who has a 4th degree perineal laceration. these can cause separation of the suture line, bleeding, or infection a. Docusate sodium is a stool softener that is often prescribed following birth. The client should take a stool softener until the perineum is healed. Hard stool can separate the suture line between the vagina and rectum, leading to bleeding and infection. b. A sitz bath filled with warm water is soothing to the perineum. The warm water also increases blood flow to the tissues, promoting healing. The nurse should encourage the client to use a sitz bath two to three times per day, or as often as needed, to decrease perineal pain. d. Ibuprofen is a nonsteroidal, anti-inflammatory medication that is used to decrease pain and swelling. The client who has a fourth-degree perineal laceration will likely receive scheduled ibuprofen as well as an opioid analgesic as needed for breakthrough pain. a nurse is caring for a client who is at 26 weeks gestation and has epilepsy. the nurse enters the room and observes the client having a seizure. after turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? a. monitor the FHR b. assess uterine activity c. administer oxygen via nonrebreather mask d. start a bolus of IV fluids c. administer oxygen via nonrebreather mask when using the ABCs approach to the client care, the nurse should take priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus a. The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. b. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. d. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next. a nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. the client appears anxious and asks the nurse if she is pregnant. which of the following responses should the nurse make? a. "you can miss you period for several other reasons. describe your typical menstrual cycle" b. "if you have been sexually active and haven't used protection, it is likely that you are pregnant" c. "let's check to see if you have any other signs of pregnancy. have you noticed any abdominal enlargement yet?" d. "because you have missed your period, you should try taking a home pregnancy test before you start worrying" a. "you can miss you period for several other reasons. describe your typical menstrual cycle" amenorrhea is a presumptive sign of pregnancy, not a positive sign. therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. b. The nurse's response dismisses the client's concerns, which can cause the client to have increased anxiety. c. The nurse's response is making a false assumption that the client is pregnant based only on the client's statement. The nurse should gather more information from the client before making any false assumptions. d. The nurse's response dismisses the client's concerns and does not answer or address the client's question, which can increase the client's anxiety level.