ATI MATERNAL NEWBORN Questions &
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A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the following
findings should the nurse report to the provider?
✓ -:- - Uterine contractions.
The client is experiencing regular uterine contractions and cervical change, which are
indicators of preterm labor; therefore, the nurse should notify the provider about this
finding.
- Gestational age.
The client is at 32 weeks of gestation and is experiencing regular uterine contractions and
cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse
should notify the provider about this finding.
- Vaginal examination.
The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in
preterm labor; therefore, the nurse should notify the provider about this finding.
The client's blood pressure is within the expected reference range . Blood pressure 130/70
mm Hg? what is normal.
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A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of
the following actions should the nurse take?
✓ -:- Report the client's condition to the local health department.
Rationale:
The nurse should report the condition to the local health department. HIV is one of the
conditions on the list of Nationally Notifiable Infectious Conditions that is required to be
reported.
Other considerations:
The nurse should tell the client that treatment for HIV will be during the prenatal and
perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug
antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during
pregnancy have been reported to decrease the transmission of the virus to the newborn.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia
purpura (ITP). Which of the following findings should the nurse expect?
✓ -:- Decreased platelet count
Rationale:
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A client who has ITP has an autoimmune response that results in a decreased platelet
count.
Other considerations:
- An increased ESR is an indication of chronic renal failure.
- An increased WBC is an indication of infection.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client
states that they are "happy one minute and crying the next." The nurse should interpret the
client's statement as an indication of which of the following?
✓ -:- Emotional lability
Rationale:
The nurse should recognize and interpret the client's statement as an indication of
emotional lability. Many clients experience rapid and unpredictable changes in mood
during pregnancy. Intense hormonal changes may be responsible for mood changes that
occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for
little or no reason.
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A nurse is assessing the newborn of a client who took a selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse
identify as an indication of withdrawal from an SSRI?
✓ -:- Vomiting
Rationale:
Expected manifestations associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
Manifestations of fetal exposure to SSRIs. include: Low birth weight, Hypoglycemia,
Tachypnea.
A nurse is assessing four newborns. Which of the following findings should the nurse report
to the provider?
✓ -:- A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
Rationale
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference
range of 36.5 - 37.5 ° C for a newborn and can be an indication of sepsis. Therefore, the
nurse should report this finding to the provider.
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