A nurse is caring for a newborn.
The nurse reviews the assessment findings and determines the findings are consistent with which of the following birth complications?
For each assessment finding, click to specify if the findings is consistent with a clavicle fracture or Erb-Duchenne paralysis. ...
MATERNAL ATI B QUESTIONS AND ANSWERS
A nurse is caring for a newborn.
The nurse reviews the assessment findings and determines the findings are consistent with which of the following birth complications?
For each assessment finding, click to specify if the findings is consistent with a clavicle fracture or Erb-Duchenne paralysis. Each finding may support more than one condition. - Answer- Clavicle fracture: - birth hx?
- crepitus - arm movement - moro reflex
- palmar grasp Erb-Duchenne paralysis: - birth hx - arm movement - moro reflex - wrist flexion - palmar grasp
A nurse is caring for a client who is pregnant.
Exhibit 1
Exhibit 2
Exhibit 3
Medical HistoryGravida 1, Para 041 weeks of gestationInduction of labor due to postdates
Which of the following actions are the nurse's priorities?
Select the 4 actions that the nurse should take immediately.
Assess cervical dilation.
Administer a bolus of IV fluids.
Insert an indwelling urinary catheter.
Reposition the client to their side.
Apply oxygen at 10 to 12 L/min by nonrebreather mask.
Elevate the client's legs.
Evaluate the client's pain level. - Answer- b. Administer a bolus of IV fluids.
- A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. The nurse should plan to administer a bolus of IV fluids to increase the client's blood volume and improve uterine and intervillous space blood flow. d. Reposition the client to their side.
- A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to turn the client to their side to increase cardiac output and improve uterine and intervillous space blood flow.
e. Apply oxygen at 10 to 12 L/min by nonrebreather mask.
- A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to administer oxygen via nonrebreather mask to increase maternal circulating oxygen levels and improve oxygen transfer through the intervillous spaces to the fetus.
f. Elevate the client's legs.
- A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. Elevating the client's legs will promote blood return to the heart and increase cardiac output. This action will improve uterine and intervillous
space blood flow.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests?
Biophysical profile
Amniocentesis
Cordocentesis
Kleihauer-Betke test - Answer- Biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.
A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?
"You will need to drink the glucose solution 2 hours prior to the test."
"Limit your carbohydrate intake for 3 days prior to the test."
"If this test is positive, you will be scheduled for a 3-hr glucose tolerance test."
"You will need to fast for 12 hours prior to the test." - Answer- "If this test is positive, you
will be scheduled for a 3-hr glucose tolerance test."
The nurse should instruct the client that if they have an elevated test result, they will be scheduled for a 3-hr glucose tolerance test. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For
which of the following complications should the nurse assess?
Abruptio placenta
Placenta previa
Preeclampsia
Maternal bradycardia - Answer- Abruptio placenta
Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that their last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?
September 3rd
September 20th
August 3rd
August 20th - Answer- September 3rd
When using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
Monitor the client's blood pressure every hour.
Restrict the total hourly intake to 200 mL.
Monitor the FHR continuously.
Administer protamine sulfate for manifestations of toxicity. - Answer- Monitor the FHR continuously.
Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia,
is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.
A nurse is performing a vaginal examination on a client who is in labor and observes the
umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?
Apply oxygen to the client at 2 L/min via nasal cannula.
Wrap the visible cord tightly with sterile, dry gauze.
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.
Place the client in the lithotomy position and apply fundal pressure. - Answer- Insert two
gloved fingers into the vagina and apply upward pressure to the presenting part.
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