ATI CAPSTONE MATERNAL-NEWBORN POST ASSESSMENT Questions and Answers.docx

  The nurse is assessing a new mother's efforts to bond with her newly born infant. Identify three (3) factors that can impact effective bonding between mother and infant? -Correct Answers: • Mother's physical and emotional condition • Baby's physical condition • Family being prepared for the baby The client enters the obstetrical clinic for birth control information on using a diaphragm. What five (5) instructions would be provided by the nurse to explain use of the diaphragm -Correct Answers: client should be properly fitted with a diaphragm by a provider Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery, and after every pregnancy Requires proper insertion and removal. Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hours after intercourse but for no more than 24 hrs Spermicide must be reapplied with each act of coitus A client should empty her bladder prior to insertion of the diaphragm.A A nurse is caring for a client who was diagnosed with group B streptococcus during her initial screening. What effects can this infection have on her pregnancy? -Correct Answers: Premature rupture of membranes, preterm labor & delivery, chorioamnioitis, infections of urinary tract, maternal sepsis. What are five (5) risk factors that affect female fertility? -Correct Answers: 1) Age greater than 35 2) Weight 3) Substance use 4) STDs 5) Surgical history A nurse is providing education to a new mother regarding storage of breast milk. Identify five (5) teaching points to discuss with the new mother regarding storage of breast milk. -Correct Answers: 1) Breast milk can be stored at room temp for up to 8 hrs, refrigerated in sterile bottles for up 8 days, and can be frozen up to 6 months, and deep-freezed for up to 12 months 2) Thaw refrigerated milks for 24 hrs to preserve immunoglobins, or by placing bottle in lukewarm water rotate but do not shake the bottle 3) Microwaving the bottle to thaw out the milk is contraindicated because it destroys the nutritive and immune properties of breastmilk, it also causes uneven heating putting the newborn at risk for burns 4) Do not refreeze thawed milk 5) used portions of breast milk must be disposed of A nurse is providing care for an uncircumcised male newborn and his mother. What information should be provided during discharge regarding bathing of the penile area of the newborn male? -Correct Answers: Wash with soap and water and rinse the penis To prevent constriction do not force back the foreskin What is the recommended weight gain in the first, second and third trimesters? -Correct Answers: 1st trimester: 1-2 kg (2.2 - 4.4 lbs) 2nd and 3rd trimester: 0.4 kg ( 1lb) per week What are six (6) emotional responses the nurse would assess for if a mother is experiencing postpartum depression? -Correct Answers: ) Feeling loss, irritability 2) Intense mood swings 3) Anxiety 4) Guilt 5) Inadequacies feelings 6) Decrease appetite What would the nurse teach to the postpartum mother before administering the Rho(D) Immune Globulin? -Correct Answers: Educate the mother that all Rh-negative mothers who have newborns who are Rh-positive must be given Rho(D) immune globulin administered IM within 72 hr of the newborn being born to suppress antibody formation in the mother. Infants who are Rh0positive are given Rho(D)Immune globulin to prevent sensitization in future pregnancies A nurse is instructing a newly diagnosed client with fibrocystic breast tissue disorder about diet. What should the nurse instruct the client to avoid in their diet? (Review the Med Surg RM) a. Alcohol b. Caffeine C. Milk d. Orange juice -Correct Answers: b. Caffeine What are five (5) adverse effects noted with epidural analgesia administration during labor? -Correct Answers: 1) Maternal Hypotension 2) Fetal Bradycardia 3) Bladder distention 4) Loss of bearing down reflex 5) Respiratory depression What should the nurse teach the client about depot medroxyprogesterone acetate as a method of contraception? -Correct Answers: Start injection during the first 5 days of the patient's menstrual cycle and every 11 - 13 weeks afterwards; For postpartum on-breastfeeding patients injections should be given 5 days of delivery, for breastfeeding women within 6 weeks; advise clients to keep up with follow-up appointments; maintain adequate intake of calcium and vitamin D A nurse is preparing to administer a rubella vaccination. What are contraindications to this immunization? (Pharmacology Review Module) -Correct Answers: Pregnancy, Immunocompromised Household Members, Hypersensitivity, Gelatin Allergy What are the indications for prescribing hormone replacement therapy (HRT) for a menopausal client? (Review Pharmacology Module) -Correct Answers: Indications can range from relieving vasomotor symptoms, improving urogenital symptoms (long-term therapy), to preventing osteoporosis A nurse is preparing to administer ibuprofen (Motrin) to a client. What are contraindications to this medication? (Review Pharmacology Module) -Correct Answers: Ibuprofen decreases the antiplatelet effect of aspirin. It can cause GI distress making it contraindicated for clients with peptic ulcers, bleeding disorders, hypersensitivity, and pregnancy. A nurse is caring for a client with placenta previa. What interventions should be completed for this client? -Correct Answers: Assess for bleeding, leakage, and contractions, fundal height, perform Leopold's maneuver, refrain from performing vaginal exams, administer IV fluids, blood products, and medications prescribed, have oxygen available After completing a thorough assessment of a large for gestational age (LGA) newborn, what education should the nurse provide to the parents regarding signs and symptoms of hypoglycemia to report to the nurse? -Correct Answers: The nurse should teach the parents to report if their newborn turns blue (cyanosis), stop breathing (apnea), have a low body temp (hypothermia), poor body tone, poor feeding, lethargic, and has seizures What are causes of late decelerations of fetal heart rate? What are nursing interventions to take if these occur? -Correct Answers: Causes for late deceleration of fetal heart rate is placental insufficiency, interventions to take in the case of this will be to stop the Pitocin, turn patient to left side, give oxygen, increase IV fluids, and alert the physician A client at 38 weeks of gestation is admitted to Labor and Delivery for the management of preeclampsia and is placed on a magnesium sulfate IV drip. Explain the signs of magnesium toxicity for which the nurse should monitor. -Correct Answers: Signs of magnesium toxicity include respiratory distress, nausea/vomiting, muscle weakness, low blood pressure, diarrhea, and urinary retention. An 8-hour post-partum client complains of abdominal cramping and feeling dizzy. During the assessment the nurse notes the client's fundus is soft, deviated to the right and 4 fingerbreadths above the umbilicus, and there is moderate rubra. What would the nurse's priority actions be? -Correct Answers: The nurse should massage the fundus until firm, replace the perineal pad with a new one and monitor closely for the saturation amount, and a presence of clots, the nurse should also assist the patient in voiding. The nurse should notify the provider of the symptoms as well.