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Maternal Newborn ATI Quizlet
1. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
- A. Fetal attitude is in general flexion.
- B. Fetal lie is longitudinal.
- C. Maternal pelvis is gynecoid.
- D. Fetal position is persistent occiput posterior.
Correct answer: D
Rationale: The correct answer is D. In a persistent occiput posterior position, the baby's head presses against the mother's spine, causing prolonged labor and severe backache. This position can lead to difficulties in labor progress and increase discomfort for the mother. Choices A, B, and C are incorrect as they do not directly relate to the client's difficult, prolonged labor with severe backache. Fetal attitude, fetal lie, and maternal pelvis type may affect labor, but in this scenario, the persistent occiput posterior fetal position is the primary contributing cause for the client's symptoms.
2. A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
- A. Assess deep tendon reflexes every hour.
- B. Obtain a daily weight.
- C. Continuous fetal monitoring
- D. Ambulate twice daily
Correct answer: D
Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.
3. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?
- A. Perform a sharp hand clap near the infant.
- B. Hold the newborn vertically allowing one foot to touch the table surface.
- C. Place a finger at the base of the newborn's toes.
- D. Turn the newborn's head quickly to one side.
Correct answer: A
Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.
4. A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?
- A. These exercises facilitate preventing constipation.
- B. These exercises aid pelvic muscle stretching during birth.
- C. They assist in decreasing backaches.
- D. They can prevent additional stretch marks.
Correct answer: B
Rationale: Kegel exercises are beneficial during pregnancy to help strengthen pelvic muscles, which is crucial for childbirth. Pelvic muscle stretching during birth is a key aspect of labor, making choice B the correct statement indicating understanding of the teaching. Choices A, C, and D are incorrect because Kegel exercises primarily focus on strengthening pelvic floor muscles to support the uterus, bladder, and bowel, aiding in labor and delivery. They are not directly related to preventing constipation, decreasing backaches, or preventing stretch marks.
5. 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.
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