LPN LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.
2. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct answer: B
Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Neonates with neonatal abstinence syndrome often display irritability, tremors, and feeding difficulties. Hyporeactivity, acrocyanosis, and a respiratory rate of 50/min are not typical manifestations of neonatal abstinence syndrome. Hyporeactivity is more associated with conditions like hypothyroidism or sepsis, acrocyanosis is a common finding in newborns due to immature peripheral circulation, and a respiratory rate of 50/min is within the normal range for a newborn.
3. A client gave birth 4 hours ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle
- B. Insert an indwelling urinary catheter
- C. Massage the client's fundus
- D. Initiate an infusion of oxytocin
Correct answer: C
Rationale: The correct answer is to massage the client's fundus first. Uterine atony is a common cause of postpartum hemorrhage, and massaging the fundus can help stimulate uterine contractions, which will assist in reducing bleeding. Elevating the client's legs to a 30° angle (Choice A) is not the priority in this situation as fundal massage takes precedence. Inserting an indwelling urinary catheter (Choice B) may be necessary but should not take precedence over managing the postpartum hemorrhage. Initiating an infusion of oxytocin (Choice D) is a valid intervention to address uterine atony, but massaging the fundus should come first to promote immediate contraction and control bleeding.
4. A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?
- A. Digoxin
- B. Calcium gluconate
- C. Vitamin B6
- D. Propranolol
Correct answer: C
Rationale: The correct answer is C: Vitamin B6 (pyridoxine). Vitamin B6 is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum. It is considered safe for use in pregnant clients. Digoxin (Choice A) is a medication used for heart conditions, not for hyperemesis gravidarum. Calcium gluconate (Choice B) is used to treat calcium deficiencies, not nausea and vomiting in pregnancy. Propranolol (Choice D) is a beta-blocker used for conditions like hypertension and anxiety, not for hyperemesis gravidarum.
5. A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 4 hours
- B. Apply moisturizing lotion to the newborn's skin every 4 hours
- C. Give the newborn 1 oz of glucose water every 4 hours
- D. Reposition the newborn every 2 to 3 hours
Correct answer: D
Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin. Checking the newborn's temperature is important, but it should be done more frequently, such as every 4 hours, to monitor for any signs of overheating or hypothermia. Applying moisturizing lotion is not indicated during phototherapy as it may interfere with the treatment. Giving glucose water is not necessary for the management of hyperbilirubinemia.
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