ATI- PN Maternal Newborn Practice 2023A Questions and Answers

ATI- PN Maternal Newborn Practice 2023A Questions and Answers A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "If my baby rides in a car with no back seat, the passenger air bag must be turned off." A nurse is assisting with collecting data from a newborn who was born 2 hours ago and has respiratory distress. Which of the following findings should the nurse report to the provider? (Select all that apply) Tachypnea Nasal flaring Retractions Expiratory grunting A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include? "You will need to be in active labor before using hydrotherapy." A nurse is assisting with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following images indicates a characteristic response to the tonic neck reflex? - Tonic neck is like a "fencer athlete" position Baby will have arm in 90 degree position as well as bent knee on the same side, other side will be straight out or a little kinked arm and leg will be straight as well. A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughter's room. Which of the following responses should the nurse make? "Let me wash my hands and then I'll take your grandson to his mother." A nurse is reviewing the laboratory results of a 4-hour-old newborn. Which of the following findings should the nurse report to the provider? Platelet count of 120,000 mm3 A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching? Breastfeed the newborn at least every 2 hours A nurse is caring for a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication? Hypertension Rationale: Methylergonovine is an oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage. It can cause nausea, vomiting, cramping, headache, and dizziness. The nurse should report changes in blood pressure to the provider because methylergonovine can cause both hypertension and hypotension. A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? Prolonged deceleration of FHR (fetal heart rate) Rationale: The nurse should report a prolonged deceleration of the FHR to the charge nurse because it can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse. The charge nurse should notify the provider about this change in FHR pattern. A nurse is caring for a client who is planning to become pregnant. The client asks the nurse who folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplements is to do which of the following? Prevent certain kinds of birth defects A nurse is assisting with the care of a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. The client has a respiratory rate of 10/min. Which of the following medications should the nurse expect a charge nurse to administer to the client? Calcium gluconate Rationale: The nurse should expect the charge nurse to administer calcium gluconate, which is an antidote for magnesium sulfate toxicity. The charge nurse will administer this medication as an IV bolus. A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements indicates an understanding of the teaching? "This medication might make me dizzy." A nurse is caring for a client 6 hours after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority? Help the client ambulate to the toilet A nurse is reinforcing teaching about food sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? 1/2 cup dried peas Rationale: Women who are pregnant should consume 600 mcg of folate per day. A half cup of dried green split peas provides 270 mcg of folate and is the best of these sources of folate for the nurse to recommend. A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? Subcutaneous Rationale: Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 hr. A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome? Reactive nonstress test Rationale: The nurse should identify that a reactive nonstress test indicates fetal well-being and is a desirable outcome. A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? Blood glucose 28 mg/dL Rationale: The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 30 to 60 mg/dL for a newborn. Therefore, the nurse should report this finding to the provider. A nurse is contributing to the plan of care for a newborn who was circumcised with a plastic bell device. Which of the following actions should the nurse include in the plan? Apply pressure with sterile gauze if bleeding occurs at the site. Rationale: The nurse should frequently monitor the site for bleeding following the procedure and apply gentle pressure using a sterile gauze square if bleeding occurs. If this does not stop the bleeding, the nurse should notify the provider. A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? Allow 20 to 30 min for feedings. Rationale: The nurse should instruct the parent to allow the newborn to feed for 20 to 30 min. This prevents the newborn from eating quickly and swallowing too much air. A nurse is collecting data from a client who is 32 hours postpartum. Which of the following findings should the nurse expect? Urine output of 3000 mL in 24 hours A nurse is caring for a client who is 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse identify as an indication that the client has hyperemesis gravidarum? Ketonuria Rationale: The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat secondary to malnutrition or starvation. A nurse on the postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? Insert an indwelling urinary catheter. Rationale: The nurse should insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria. A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching? "Your fluid intake will be limited to no mare than 125 milliliters per hour." A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will apply cold cabbage leaves to my breast throughout the day." A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? Hematocrit 30% Rationale: The nurse should identify that a hematocrit of 30% is below the expected reference range of greater than 33% for a client who is pregnant. A low Hct is an indication of anemia. Therefore, the nurse should report this finding to the provider. A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take? Explain to the client that she will receive the hepatitis B immune globulin immediately. A nurse is discussing family planning with a client who is requesting information about available contraceptive methods. Which of the following client statements indicates an understanding of the teaching? "I should use water-soluble lubricant when my partner wears a condom." A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? "I will ask the nurse to take care of my baby in the nursery if I need to take a nap." A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider? Blurred vision Rationale: The nurse should report blurred vision to the provider as it is an indication that the client might have preeclampsia.