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ATI Capstone Maternal Newborn Assessment 2023 Questions and Correct Answers
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ATI Capstone Maternal Newborn Assessment 2023 Questions and Correct Answers
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ATI Capstone Maternal Newborn Assessmen t 2023 Questions and Correct Answers A nurse is caring for a client at the prenatal clinic who is at 38 weeks gestation with heavy, red vaginal bleeding without contractions that started spontaneously. She is in no distress and states that she can "feel the baby moving". The nurse should expl ain to the client that the stat ultrasound the provider prescribed will determine 1. fetal lung maturity 2. location of the placenta 3. fetal viability 4. biparietal diameter - ANSWERS -Location of the placenta; painless, spontaneous vaginal bleeding may be an indication of placenta previa. The provider can identify the location of the placenta and urgency of the delivery. A nurse is caring for a client in the prenatal clinic with a possible ectopic pregnancy at 8 weeks of gestation. Which of the followin g is an expected finding for this client? 1. uterine enlargement greater than expected for gestational age 2. copious vaginal bleeding 3. severe nausea and vomiting 4. pelvic pain - ANSWERS -Pelvic pain; early sign of ectopic pregnancy. Two hours after a s pontaneous vaginal delivery, a client has saturated two perineal pads with blood in a 30 -min period. Which of the following actions is the priority for the nurse to take at this time? 1. check the consistency of the client's uterine fundus . 2. have the cli ent use the bedpan to urinate 3. prepare to administer oxytocin medication 4. increase the client's fluid intake - ANSWERS -Check the consistency of the client's uterine fundus; saturating a perineal pad in 15 min or less indicates excessive blood loss. If the fundus is boggy, fundal massage might control the bleeding. When collecting data from a postpartum client 1 hr after delivery, the nurse finds large amount of lochia rubra on the client's perineal pad with several small clots. The fundus is midline an d firm at the umbilicus. Which of the following is appropriate nursing action at this time? 1. Call the client's provider 2. Continue to monitor the client's fundus 3. Increase the rate of the IV fluids 4. Assist the client to the bathroom so she can empty her bladder. - ANSWERS -Continue to monitor the client's fundus. These findings are expected. Small clots are common in lochia rubra, but large or moderate sized clots would be cause for concern. A nurse is caring for a client who is admitted in preterm l abor at 32 weeks of gestation. Which of the following prescriptions should the nurse question? 1. folic acid 2. Ritodrine (Yutopar) 3. Misoprostol (Cytotec) 4. Terbutaline sulfate (Brethine) - ANSWERS -Misoprostol (Cytotec); this medication can cause abortion, premature labor, and birth defects. A nurse is caring for an infant who has hydrocephalus. Which of the following manifestations should the nurse expect to find? 1. proteinuria 2. dilated scalp veins 3. hypertension 4. pulsatile fontanels - ANSWERS -Dilated scalp veins; manifestations of hydrocephalus in infancy include dilated scalp veins, separated sutures, and frontal enlargement in late infancy. A nurse is caring for a client who might have hydatidiform mole. The nurse should monitor the client for which of the following findings? 1. Fetal heart rate irregularities 2. Whitish vaginal discharge 3. Excessive uterine enlargement 4. Rapidly dropping hCG l evels - ANSWERS -Excessive uterine enlargement; hydatidiform mole is a rare rumor that arises from placental tissue and results in a rapidly enlarging uterus. Serum hCG levels will be elevated, there is no developing fetus, and there is bright red or dark b rown vaginal discharge in later stages. A nurse is talking with a client who is at 6 weeks gestation. The client smokes one pack of cigarettes a day. The nurse should explain that newborns of women who smoke are at particular risk for 1. hearing loss 2. intrauterine growth retardation 3. gestational diabetes 4. congenital heart defects - ANSWERS -Intrauterine growth retardation; other complications include placental abruption, placenta previa, preterm delivery, and fetal death. A nurse is caring for a clie nt who is in preterm labor and will undergo amniocentesis. When the client asks what the test will determine, the nurse should respond with which of the following? 1. maturity of lungs 2. weeks of gestation 3. gender of the fetus 4. the etiology of the lab or - ANSWERS -Maturity of lungs; amniocentesis is the best way to determine fetal lung maturity. The L/S ratio measures the amount of lung enzyme surfactant. 2:1 or greater means the lungs are mature enough to withstand extrauterine life. A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and blurred vision. The client's blood glucose is 46 mg/dL. Which of the following is appropriate to give the client? (SATA) - 120 mL unsweetened fruit juice - 1 tbsp honey - 5 hard candies - 240 mL regular soda - 120 mL milk - ANSWERS -120 mL unsweetened fruit jucie; 1 tbsp honey; 5 hard candies A nurse is caring for a client who experienced abruption placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse recognizes this client is at risk for which of the following postpartum complications? 1. amniotic fluid embolism 2. disseminated intravascular coagulation 3. preeclampsia 4. puerperal infection - ANSWERS -Disseminated intravascular coagula tion; manifestations of DIC include oozing from IV access and venipuncture sites, petechiae, spontaneous bleeding, signs of bruising, and hematuria. A nurse is collecting data from a client who has just had a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen? 1. at the level of the umbilicus 2. three fingers breadths above the umbilicus 3. one finger breadth above the symphysis pubis 4. to the right of the umbilicus - ANSWERS -At the levels of the umbilicus; within 12 hours, the fundus should rise just about to the level of the umbilicus and then recede 1 -
2 cm each day. A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforc e to the client to call her provider if she experiences which of the following? 1. decreased energy 2. urinary frequency 3. facial edema 4. mood swings - ANSWERS -Facial edema; this is an indication of pregnancy -induced hypertension and should be reported. Common symptoms of pregnancy are reduced energy levels, urinary frequency, and mood swings. A client is reporting unrelieved episiotomy pain 8 hours after delivery. Which of the following actions should the client's nurse take? 1. apply an ice pack to the perineum
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