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PN ATI Capstone Maternal Newborn
1. A client in labor has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria
- B. Hypertension
- C. Pruritus
- D. Dry mouth
Correct answer: C
Rationale: Pruritus is a common adverse effect of epidural anesthesia, often due to the opioids administered with the epidural. It presents as itching on the skin and can cause significant discomfort to the client. Polyuria (excessive urination) and dry mouth are not typical adverse effects of epidural anesthesia. Hypertension is not commonly associated with epidural anesthesia; in fact, hypotension is a more frequent complication due to sympathetic blockade. Therefore, the correct answer is pruritus (choice C), as it is a known adverse effect of epidural anesthesia.
2. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 minutes
- B. Contraction duration of 100 seconds
- C. Fetal heart rate with moderate variability
- D. Fetal heart rate of 118/min
Correct answer: B
Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. Prolonged contractions may reduce oxygen supply to the fetus, putting it at risk. Discontinuing the oxytocin infusion is crucial to prevent adverse effects on both the mother and the fetus. The other options do not raise immediate concerns that would necessitate discontinuing the oxytocin infusion. Contraction frequency every 3 minutes is within a normal range. Fetal heart rate with moderate variability and a rate of 118/min are both reassuring signs of fetal well-being.
3. A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?
- A. Encourage the mother to breastfeed the newborn
- B. Gavage feed 60 mL (2 oz) of glucose water
- C. Administer 10 mL of D5W via IV
- D. Recheck the glucose level in 2 hours
Correct answer: A
Rationale: Encouraging the mother to breastfeed the newborn is the most appropriate action in this scenario. Breastfeeding can quickly raise blood glucose levels in newborns. A blood glucose level of 45 mg/dL is often acceptable in newborns, but close monitoring is necessary. Gavage feeding with glucose water or administering D5W via IV may not be necessary at this point and could lead to potential risks of overfeeding or hypoglycemia. Rechecking the glucose level in 2 hours may delay necessary intervention, as breastfeeding can promptly address the low blood glucose levels.
4. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.
5. Before an amniocentesis, what action by the client will need to be completed?
- A. Increase fluid intake
- B. Empty the bladder
- C. Avoid eating for 12 hours
- D. Take a sedative
Correct answer: B
Rationale: Before an amniocentesis, the client should empty their bladder. This is necessary to reduce the risk of bladder puncture during the procedure. A full bladder can be in the path of the needle, increasing the risk of injury. Increasing fluid intake (choice A) is not necessary before an amniocentesis. Avoiding eating for 12 hours (choice C) is not a standard preparation for an amniocentesis. Taking a sedative (choice D) is not routinely required for this procedure.
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