Maternal Newborn ATI
A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of
the following assessments is the nurse’s priority?
**Amount of lochia**
- When using the airway, breathing, circulation approach to client care, the nurse
should place the priority in the immediate postpartum period on assessing the
amount of postpartum lochia. The greatest risk to the client is bleeding and
postpartum hemorrhage.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput
posterior position. The client is dilated to 8 cm and reports back pain. Which of the
following actions should the nurse take?
**Apply sacral counterpressure**
- Sacral counterpressure assists in relieving back labor pain related to fetal
posterior position.
A nurse is demonstrating to a client how to bathe her newborn. In which order should
the nurse perform the following actions?
**Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck
by lifting the newborn’s chin. Cleanse the skin around the newborn’s umbilical cord
stump. Wash the newborn’s legs and feet. Clean the newborn’s diaper area.**
- Use a head to toe, clean to dirty approach when washing a newborn.
A nurse is caring for a client and her partner who have experienced a fetal death. Which
of the following actions should the nurse take?
**Take photos of the newborn to give to the parents.**
- The nurse should create a memory box that includes mementos of the newborn
(ex: photos, the newborn’s ID bands, the newborn’s hat, & the newborn’s
blanket).
A nurse is caring for a client who is at 36 weeks of gestation and has a positive
contraction stress test. The nurse should plan to prepare the client for which of the
following diagnostic tests?
**Biophysical profile**
- A positive contraction stress test indicates that further evaluation of the fetus is
necessary (baby’s heart slowed or showed abnormality during contraction). A
biophysical profile will provide further evaluation with real-time ultrasound.
,A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to the
provider?
**Platelets 50,000/mm3**
- A platelet count of 50,000/mm3 is below the expected reference range, which
can indicate disseminated intravascular coagulation. The nurse should report this
result to the provider.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?
**Minimal arm recoil**
- The nurse should expect a newborn who was born at 26 weeks gestation to have
decreased muscular tone, or minimal arm recoil.
A nurse is assessing a newborn following circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
**Chin quivering**
- Behavioral responses to a newborn’s pain include facial expressions (ex: chin
quivering, grimacing, & furrowing of the brow).
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**
- Expected clinical manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, & vomiting. These usually last 2 days.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
**Remove all clothing from the newborn except the diaper.**
- The nurse should remove all of the newborn’s clothing except the diaper while
under phototherapy. Maximum skin exposure to the ultraviolet light is needed to
break down the excess bilirubin.
A nurse is creating a plan of care for a client who is postpartum and adheres to
traditional Hispanic cultural beliefs. Which of the following cultural practices should the
nurse include in the plan of care?
**Protect the client’s head and feet from cold air.**
, - Protecting the client’s head and feet from cold air should be included in the plan
of care because this is a traditional Hispanic practice during the postpartum
period. Hispanic practices also include delaying bathing for 14 days, bed rest for
3 days, and drinking warm beverages following delivery.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal
monitoring?
**Perform Leopold maneuvers.**
- The nurse should perform Leopold maneuvers to assess the position of the fetus
to best determine the optimal placement for the external fetal monitoring
transducer.
A nurse is caring for a client who is in active labor and has had no cervical change in
the last 4 hours. Which of the following statements should the nurse make?
**”Your provider will insert an intrauterine pressure catheter to monitor the strength of
your contractions.”**
- Insertion of an intrauterine pressure catheter is necessary to determine uterine
contraction intensity, which will identify whether or not the contractions are
adequate for the progression of labor.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic
shock. After notifying the provider, which of the following actions should the nurse take
next?
**Massage the client’s fundus.**
- The greatest risk to the client is hemorrhage. Therefore, the next action the nurse
should take is to massage the client’s fundus to expel clots and promote
contractions.
A nurse is reviewing the medical record of a client who is one day postpartum. The
client had a vaginal birth with a fourth-degree perineal laceration. The nurse should
contact the provider regarding which of the following prescriptions?
**Bisacodyl rectal suppository daily as needed for constipation**
- The nurse should not administer a rectal suppository or enema to a client who
has a fourth-degree perineal laceration. These can cause separation of the
suture line, bleeding, or infection.
A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurse
enters the room and observes the client having a seizure. After turning the client’s head
to one side, which of the following actions should the nurse take immediately after the
seizure?
A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of
the following assessments is the nurse’s priority?
**Amount of lochia**
- When using the airway, breathing, circulation approach to client care, the nurse
should place the priority in the immediate postpartum period on assessing the
amount of postpartum lochia. The greatest risk to the client is bleeding and
postpartum hemorrhage.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput
posterior position. The client is dilated to 8 cm and reports back pain. Which of the
following actions should the nurse take?
**Apply sacral counterpressure**
- Sacral counterpressure assists in relieving back labor pain related to fetal
posterior position.
A nurse is demonstrating to a client how to bathe her newborn. In which order should
the nurse perform the following actions?
**Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck
by lifting the newborn’s chin. Cleanse the skin around the newborn’s umbilical cord
stump. Wash the newborn’s legs and feet. Clean the newborn’s diaper area.**
- Use a head to toe, clean to dirty approach when washing a newborn.
A nurse is caring for a client and her partner who have experienced a fetal death. Which
of the following actions should the nurse take?
**Take photos of the newborn to give to the parents.**
- The nurse should create a memory box that includes mementos of the newborn
(ex: photos, the newborn’s ID bands, the newborn’s hat, & the newborn’s
blanket).
A nurse is caring for a client who is at 36 weeks of gestation and has a positive
contraction stress test. The nurse should plan to prepare the client for which of the
following diagnostic tests?
**Biophysical profile**
- A positive contraction stress test indicates that further evaluation of the fetus is
necessary (baby’s heart slowed or showed abnormality during contraction). A
biophysical profile will provide further evaluation with real-time ultrasound.
,A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to the
provider?
**Platelets 50,000/mm3**
- A platelet count of 50,000/mm3 is below the expected reference range, which
can indicate disseminated intravascular coagulation. The nurse should report this
result to the provider.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?
**Minimal arm recoil**
- The nurse should expect a newborn who was born at 26 weeks gestation to have
decreased muscular tone, or minimal arm recoil.
A nurse is assessing a newborn following circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
**Chin quivering**
- Behavioral responses to a newborn’s pain include facial expressions (ex: chin
quivering, grimacing, & furrowing of the brow).
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**
- Expected clinical manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, & vomiting. These usually last 2 days.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
**Remove all clothing from the newborn except the diaper.**
- The nurse should remove all of the newborn’s clothing except the diaper while
under phototherapy. Maximum skin exposure to the ultraviolet light is needed to
break down the excess bilirubin.
A nurse is creating a plan of care for a client who is postpartum and adheres to
traditional Hispanic cultural beliefs. Which of the following cultural practices should the
nurse include in the plan of care?
**Protect the client’s head and feet from cold air.**
, - Protecting the client’s head and feet from cold air should be included in the plan
of care because this is a traditional Hispanic practice during the postpartum
period. Hispanic practices also include delaying bathing for 14 days, bed rest for
3 days, and drinking warm beverages following delivery.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal
monitoring?
**Perform Leopold maneuvers.**
- The nurse should perform Leopold maneuvers to assess the position of the fetus
to best determine the optimal placement for the external fetal monitoring
transducer.
A nurse is caring for a client who is in active labor and has had no cervical change in
the last 4 hours. Which of the following statements should the nurse make?
**”Your provider will insert an intrauterine pressure catheter to monitor the strength of
your contractions.”**
- Insertion of an intrauterine pressure catheter is necessary to determine uterine
contraction intensity, which will identify whether or not the contractions are
adequate for the progression of labor.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic
shock. After notifying the provider, which of the following actions should the nurse take
next?
**Massage the client’s fundus.**
- The greatest risk to the client is hemorrhage. Therefore, the next action the nurse
should take is to massage the client’s fundus to expel clots and promote
contractions.
A nurse is reviewing the medical record of a client who is one day postpartum. The
client had a vaginal birth with a fourth-degree perineal laceration. The nurse should
contact the provider regarding which of the following prescriptions?
**Bisacodyl rectal suppository daily as needed for constipation**
- The nurse should not administer a rectal suppository or enema to a client who
has a fourth-degree perineal laceration. These can cause separation of the
suture line, bleeding, or infection.
A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurse
enters the room and observes the client having a seizure. After turning the client’s head
to one side, which of the following actions should the nurse take immediately after the
seizure?
