ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. 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.
2. A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?
- A. Administer 1 oz of glucose water every 2 hours
- B. Feed the newborn 60 mL of formula every 4 hours
- C. Offer sterile water between feedings
- D. Initiate phototherapy
Correct answer: D
Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.
3. A nurse is providing care to a client who is in active labor. The nurse observes variable decelerations in the fetal heart rate. Which of the following actions should the nurse take first?
- A. Administer oxygen at 10 L/min via face mask
- B. Reposition the client from side to side
- C. Increase the rate of the IV infusion
- D. Notify the provider
Correct answer: B
Rationale: The correct action the nurse should take first when observing variable decelerations in the fetal heart rate is to reposition the client from side to side. Variable decelerations are often caused by umbilical cord compression, and repositioning the client can relieve pressure on the cord. Administering oxygen, increasing the IV infusion rate, and notifying the provider can be appropriate actions but repositioning the client takes priority in addressing variable decelerations.
4. A nurse is preparing to administer terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client is an indication that the medication is effective?
- A. I feel like my contractions are getting stronger.
- B. I feel like my heart is racing.
- C. My baby is moving less than before.
- D. My contractions have stopped.
Correct answer: D
Rationale: Terbutaline is a tocolytic medication used to stop uterine contractions. The client stating that the contractions have stopped indicates that the medication is effective. Choices A, B, and C are incorrect because feeling stronger contractions, a racing heart, or decreased fetal movement are not signs of terbutaline effectiveness in managing preterm labor.
5. A nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 70/min
- B. Vernix caseosa covering the skin
- C. Milia on the bridge of the nose
- D. Acrocyanosis of the extremities
Correct answer: A
Rationale: A respiratory rate of 70/min in a newborn is above the expected range and may indicate respiratory distress, which should be reported to the provider. Choice B, vernix caseosa covering the skin, is a normal finding in newborns and does not require reporting. Choice C, milia on the bridge of the nose, is also a common finding in newborns and does not require immediate reporting. Choice D, acrocyanosis of the extremities, is a common finding within the first few hours of life in newborns and typically resolves on its own, so it does not need to be reported.
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