Dyersburg State Community College - BIOLOGY 2010 - Maternal Newborn Study Guide.

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.**