ATI RN Maternal Newborn A
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight
3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of
methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier
but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation.
Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive
Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn urine toxicology
screen positive for opiates (- - ANSWER: Respiratory findings is incorrect. The
newborn's respiratory rate is within the expected reference range of 30 to 60/min. There
is no indication the newborn has an alteration in respiratory status; therefore, this finding
does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected
reference range of greater than 94%; therefore, this finding does not need to be
reported to the provider.
Central nervous system findings is correct. The newborn is displaying inconsolability,
high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and
excessive sucking. These findings are manifestations of NAS and should be reported to
the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose
stools. These findings are manifestations of NAS and should be reported to the
provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
@0930: Client passed large amount of bright red blood from vagina. Denies pain.
Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
,Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood
pressure 112/64 mmHg. Fetal heart rate 132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min
Exhibit 3: Medical hx
G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section -
ANSWER: When generating solutions, inserting a large bore intravenous catheter is
indicated. Clients who have third trimester vaginal bleeding may experience a sudden
hemorrhage and require fluid resuscitation or the administration of blood products. The
nurse should weigh perineal pads. Weighing perineal pads after use will provide a more
accurate assessment of the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer methotrexate or assess for
cervical dilation because it is contraindicated for this client. Methotrexate is an
antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be
administered during pregnancy to medically resolve an ectopic pregnancy during the
first trimester. Assessing cervical dilation is contraindicated for any pregnant client who
is experiencing vaginal bleeding. Manipulation of the cervix during the examination may
result in further damage to the placenta and compromise the well-being of the client and
fetus.
A nurse is assessing the newborn of a client who took selective serotonin reuptake
inhibitor (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 - ANSWER: d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client's history should the nurse
recognize as a contraindication to oral contraceptives? (Select all that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder - ANSWER: Cholecystitis, hypertension, and migraine headaches is
correct. A history of gallbladder disease is a contraindication for the use of oral
contraceptives. Hypertension is a contraindication for the use of oral contraceptives. A
history of migraine headaches is a contraindication for the use of oral contraceptives.
, HPV and anxiety disorder is incorrect. The presence of human papillomavirus is not a
contraindication for the use of oral contraceptives. The presence of an anxiety disorder
is not a contraindication for the use of oral contraceptives.
A nurse is caring for a newborn.
Exhibit 1: Medical hx
@1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight 4,706g (10lb 6oz).
Gestational age 40 weeks. Difficult vaginal birth with shoulder dystocia.
Exhibit 2: RN note
@1700: Newborn is active and moves all extremities except for right arm. No
spontaneous movement of the right arm noted. Right arm remains at side during Moro
reflex.
Exhibit 3: Physical Exam
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm
pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-
Duchenne (Erb's palsy) paralysis. - ANSWER: Educate the parents to begin range of
motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises
of the arm are indicated to restore function of the extremity. The initiation of these
exercises is delayed for approximately 1 week to prevent additional injury to the brachial
plexus.
Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne
paralysis, only the upper arm is affected. The function of the wrists and fingers should
be unaffected; the nurse should assess for a palmar grasp reflex.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is
indicated. Intermittent immobilization of the affected arm across the newborn's abdomen
can be achieved by pinning the sleeve to the shirt.
Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and
guardians should participate in the physical care of their newborn to increase parental-
infant attachment. Providing education and practice opportunities for the parents will
decrease their fears of injuring the newborn and increase confidence and bonding.
A nurse is admitting a client to the labor and delivery unit when the client states, "My
water just broke." Which of the following interventions is the nurse's priority?
a. Perform Nitrazine testing
b. Assess the fluid
c. Check cervical dilation
d. Begin FHR monitoring - ANSWER: d. Begin FHR monitoring
The greatest risk to the client and their fetus following a rupture of membranes is
umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-
being. Therefore, this is the priority action the nurse should take.
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight
3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of
methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier
but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation.
Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive
Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn urine toxicology
screen positive for opiates (- - ANSWER: Respiratory findings is incorrect. The
newborn's respiratory rate is within the expected reference range of 30 to 60/min. There
is no indication the newborn has an alteration in respiratory status; therefore, this finding
does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected
reference range of greater than 94%; therefore, this finding does not need to be
reported to the provider.
Central nervous system findings is correct. The newborn is displaying inconsolability,
high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and
excessive sucking. These findings are manifestations of NAS and should be reported to
the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose
stools. These findings are manifestations of NAS and should be reported to the
provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
@0930: Client passed large amount of bright red blood from vagina. Denies pain.
Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
,Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood
pressure 112/64 mmHg. Fetal heart rate 132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min
Exhibit 3: Medical hx
G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section -
ANSWER: When generating solutions, inserting a large bore intravenous catheter is
indicated. Clients who have third trimester vaginal bleeding may experience a sudden
hemorrhage and require fluid resuscitation or the administration of blood products. The
nurse should weigh perineal pads. Weighing perineal pads after use will provide a more
accurate assessment of the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer methotrexate or assess for
cervical dilation because it is contraindicated for this client. Methotrexate is an
antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be
administered during pregnancy to medically resolve an ectopic pregnancy during the
first trimester. Assessing cervical dilation is contraindicated for any pregnant client who
is experiencing vaginal bleeding. Manipulation of the cervix during the examination may
result in further damage to the placenta and compromise the well-being of the client and
fetus.
A nurse is assessing the newborn of a client who took selective serotonin reuptake
inhibitor (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 - ANSWER: d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client's history should the nurse
recognize as a contraindication to oral contraceptives? (Select all that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder - ANSWER: Cholecystitis, hypertension, and migraine headaches is
correct. A history of gallbladder disease is a contraindication for the use of oral
contraceptives. Hypertension is a contraindication for the use of oral contraceptives. A
history of migraine headaches is a contraindication for the use of oral contraceptives.
, HPV and anxiety disorder is incorrect. The presence of human papillomavirus is not a
contraindication for the use of oral contraceptives. The presence of an anxiety disorder
is not a contraindication for the use of oral contraceptives.
A nurse is caring for a newborn.
Exhibit 1: Medical hx
@1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight 4,706g (10lb 6oz).
Gestational age 40 weeks. Difficult vaginal birth with shoulder dystocia.
Exhibit 2: RN note
@1700: Newborn is active and moves all extremities except for right arm. No
spontaneous movement of the right arm noted. Right arm remains at side during Moro
reflex.
Exhibit 3: Physical Exam
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm
pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-
Duchenne (Erb's palsy) paralysis. - ANSWER: Educate the parents to begin range of
motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises
of the arm are indicated to restore function of the extremity. The initiation of these
exercises is delayed for approximately 1 week to prevent additional injury to the brachial
plexus.
Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne
paralysis, only the upper arm is affected. The function of the wrists and fingers should
be unaffected; the nurse should assess for a palmar grasp reflex.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is
indicated. Intermittent immobilization of the affected arm across the newborn's abdomen
can be achieved by pinning the sleeve to the shirt.
Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and
guardians should participate in the physical care of their newborn to increase parental-
infant attachment. Providing education and practice opportunities for the parents will
decrease their fears of injuring the newborn and increase confidence and bonding.
A nurse is admitting a client to the labor and delivery unit when the client states, "My
water just broke." Which of the following interventions is the nurse's priority?
a. Perform Nitrazine testing
b. Assess the fluid
c. Check cervical dilation
d. Begin FHR monitoring - ANSWER: d. Begin FHR monitoring
The greatest risk to the client and their fetus following a rupture of membranes is
umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-
being. Therefore, this is the priority action the nurse should take.
