ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. 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.
2. A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?
- A. You should avoid lifting anything heavier than your newborn
- B. You should not lift anything heavier than your newborn
- C. You should wait 1 week before driving
- D. You can resume sexual activity in 2 weeks
Correct answer: B
Rationale: The correct instruction for a client who is postpartum and had a cesarean birth is to not lift anything heavier than her newborn. This precaution is crucial to prevent injury to the healing incision site and allow for proper recovery. Choice A is incorrect as it implies resuming abdominal exercises in 2 weeks, which may strain the incision area. Choice C is incorrect because the client should wait longer than 1 week before driving to ensure they can perform emergency maneuvers if needed. Choice D is incorrect as resuming sexual activity in 2 weeks may put strain on the healing tissues and increase the risk of complications.
3. A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?
- A. 1+ proteinuria
- B. Blood pressure 144/92 mm Hg
- C. Respiratory rate 22/min
- D. Urine output 20 mL/hr
Correct answer: D
Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.
4. A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?
- A. Contraction frequency of every 3 minutes
- B. Contraction duration of 80 seconds
- C. Late decelerations in the fetal heart rate
- D. Urine output of 50 mL/hr
Correct answer: C
Rationale: Late decelerations in the fetal heart rate require immediate intervention as they can indicate fetal distress due to uteroplacental insufficiency. This finding suggests a compromised blood flow to the fetus, which can lead to serious complications if not addressed promptly. Contraction frequency and duration are important to monitor but do not necessitate immediate intervention unless they are causing fetal distress. Urine output of 50 mL/hr is within the normal range for a client in labor and does not require immediate intervention.
5. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?
- A. Caput succedaneum
- B. Jaundice
- C. Acrocyanosis
- D. Overlapping cranial sutures
Correct answer: B
Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99