ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?
- A. Continue to monitor the fetal heart rate
- B. Reposition the client
- C. Administer oxygen via face mask
- D. Increase the rate of the IV fluids
Correct answer: A
Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.
2. A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 10/min
- B. Urine output of 30 mL/hr
- C. Deep tendon reflexes 2+
- D. Client reports feeling warm
Correct answer: A
Rationale: A respiratory rate of 10/min is significantly low and indicates potential magnesium toxicity, which can lead to respiratory depression. This finding should be reported to the provider immediately for further evaluation and management. Urine output of 30 mL/hr is within the expected range during magnesium sulfate therapy and does not require immediate reporting. Deep tendon reflexes 2+ are a normal finding and do not indicate any immediate concerns. The client reporting feeling warm is a common side effect of magnesium sulfate and does not require immediate reporting unless accompanied by other symptoms.
3. A nurse is assessing a client who is at 35 weeks of gestation and has suspected placenta previa. Which of the following findings should the nurse expect?
- A. Painless vaginal bleeding
- B. Severe abdominal pain
- C. Uterine contractions
- D. Increased fetal movement
Correct answer: A
Rationale: Correct. Placenta previa typically presents with painless vaginal bleeding as the placenta is located over or near the cervical opening. This bleeding occurs because the placental vessels are stretched and bleed easily. Severe abdominal pain (choice B) is not a typical finding in placenta previa. Uterine contractions (choice C) are more characteristic of preterm labor rather than placenta previa. Increased fetal movement (choice D) is not a specific finding associated with placenta previa.
4. A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?
- A. Contraction frequency of 2 minutes
- B. Contraction duration of 90 seconds
- C. Fetal heart rate of 150/min
- D. Urine output of 60 mL/hr
Correct answer: B
Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.
5. A healthcare provider is assessing a newborn who is 12 hours old. Which of the following findings should the provider report?
- A. Respiratory rate 50/min
- B. Blood glucose 30 mg/dL
- C. Blood pressure 60/40 mm Hg
- D. Heart rate 140/min
Correct answer: B
Rationale: A blood glucose level of 30 mg/dL in a newborn is significantly low and indicates hypoglycemia, which can be dangerous in a newborn. Hypoglycemia in a newborn can lead to neurological issues and requires immediate attention. The other findings provided, such as a respiratory rate of 50/min, blood pressure of 60/40 mm Hg, and a heart rate of 140/min, are within normal ranges for a newborn and do not require immediate reporting unless accompanied by clinical signs of distress.
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