ATI RN Maternal Newborn A
Study online at https://quizlet.com/_em68fb
1. 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 toxicol-
ogy screen positive for opiates (-: 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.
2. 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.
, ATI RN Maternal Newborn A
Study online at https://quizlet.com/_em68fb
@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 sec-
tion: 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.
3. A nurse is assessing the newborn of a client who took selective serotonin
reuptake inhibitor (SSRI) during pregnancy. Which of the following manifesta-
tions should the nurse identify as an indication of withdrawal from an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting: d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and
vomiting. These manifestations typically last 2 days.
, ATI RN Maternal Newborn A
Study online at https://quizlet.com/_em68fb
4. 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: 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.
5. 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.: 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
Study online at https://quizlet.com/_em68fb
1. 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 toxicol-
ogy screen positive for opiates (-: 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.
2. 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.
, ATI RN Maternal Newborn A
Study online at https://quizlet.com/_em68fb
@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 sec-
tion: 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.
3. A nurse is assessing the newborn of a client who took selective serotonin
reuptake inhibitor (SSRI) during pregnancy. Which of the following manifesta-
tions should the nurse identify as an indication of withdrawal from an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting: d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and
vomiting. These manifestations typically last 2 days.
, ATI RN Maternal Newborn A
Study online at https://quizlet.com/_em68fb
4. 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: 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.
5. 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.: 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
