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Maternal Newborn ATI Quizlet
1. A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
- A. Placenta previa
- B. Prolapsed cord
- C. Incompetent cervix
- D. Abruptio placentae
Correct answer: D
Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall, which can cause continuous abdominal pain and vaginal bleeding. In this scenario, the client's symptoms of sudden abdominal pain and vaginal bleeding are indicative of abruptio placentae, which requires immediate medical attention to prevent potential complications for both the client and the fetus. Placenta previa is characterized by painless vaginal bleeding in the third trimester, not sudden abdominal pain. Prolapsed cord presents with visible umbilical cord protruding from the vagina and is not associated with abruptio placentae symptoms. Incompetent cervix typically manifests as painless cervical dilation in the second trimester, not sudden abdominal pain and bleeding as seen in abruptio placentae.
2. A client who is at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding, with a tentative diagnosis of inevitable abortion. Which of the following nursing interventions should be included in the plan of care?
- A. Administer oxygen via nasal cannula.
- B. Offer the option to view products of conception.
- C. Instruct the client to increase potassium-rich foods in the diet.
- D. Maintain the client on bed rest.
Correct answer: B
Rationale: In cases of inevitable abortion, offering the option to view products of conception can assist in emotional healing and closure for the client. This can provide a sense of acknowledgment and closure for the loss experienced, aiding in the grieving process. Administering oxygen via nasal cannula (choice A) is not directly related to the emotional and psychological support needed during an inevitable abortion. Instructing the client to increase potassium-rich foods (choice C) may not be a priority in this situation. Maintaining the client on bed rest (choice D) may be indicated in some cases but does not address the emotional aspect of the situation.
3. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?
- A. Maternal/newborn blood group incompatibility
- B. Absence of vitamin K
- C. Physiologic jaundice
- D. Maternal cocaine abuse
Correct answer: A
Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.
4. During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?
- A. Vertex
- B. Shoulder
- C. Breech
- D. Mentum
Correct answer: C
Rationale: The correct answer is C: "Breech." The RSA position indicates that the fetus is in a breech presentation. In a breech presentation, the buttocks or feet are positioned to be delivered first, which can impact the mode of delivery and require close monitoring during labor and birth. Choice A (Vertex) refers to the head-first presentation, which is considered the normal and most common presentation for birth. Choice B (Shoulder) does not represent a specific fetal presentation. Choice D (Mentum) refers to the chin presentation, which is also not relevant in this scenario.
5. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?
- A. Evaluate the firmness of the uterus.
- B. Initiate oxygen therapy via a non-rebreather mask.
- C. Administer oxytocin infusion.
- D. Obtain a type and crossmatch.
Correct answer: A
Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.
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