ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?
- A. Hyperbilirubinemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypothermia
Correct answer: B
Rationale: Newborns who are large for gestational age (LGA) are at risk for hypoglycemia due to increased insulin production. Hyperbilirubinemia (Choice A) is more commonly associated with ABO or Rh incompatibility. Hypercalcemia (Choice C) is not a common finding in LGA newborns. Hypothermia (Choice D) may occur in newborns who are small for gestational age (SGA) due to a lack of subcutaneous fat for insulation, but it is not typically associated with LGA newborns.
2. 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.
3. A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?
- A. Avoid using a breast pump.
- B. Apply breast milk to the nipples after feedings.
- C. Feed the newborn less frequently.
- D. Use a nipple shield during feedings.
Correct answer: B
Rationale: The correct instruction for the nurse to provide is to advise the client to apply breast milk to the nipples after feedings. Breast milk has healing properties and can help soothe sore nipples. Option A is incorrect because avoiding the use of a breast pump does not directly address nipple soreness. Option C is incorrect as feeding the newborn less frequently can lead to engorgement and further complications. Option D is incorrect as using a nipple shield during feedings may not address the underlying issue of soreness and can sometimes even worsen the situation.
4. 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.
5. 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.
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