ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?
- A. Feed the newborn on demand
- B. Apply warm compresses to the breast before feeding
- C. Massage the breast after feedings
- D. Ensure the newborn empties one breast before switching to the other
Correct answer: D
Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.
2. A client who is breastfeeding is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Breastfeed the newborn every 2 hours
- B. Offer both breasts at each feeding
- C. Supplement feedings with formula at night
- D. Expect the newborn to sleep through the night at 1 month
Correct answer: B
Rationale: The correct instruction for the nurse to include is to offer both breasts at each feeding. This practice helps ensure the baby receives hindmilk from both breasts, promoting adequate milk intake and stimulating milk production. Option A is incorrect as newborns should be breastfed on demand rather than on a strict schedule. Option C is inappropriate as it can interfere with establishing and maintaining a sufficient milk supply. Option D is inaccurate as newborns typically do not sleep through the night at one month; they need to feed frequently for proper growth and development.
3. 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.
4. A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?
- A. Rh incompatibility
- B. Severe preeclampsia
- C. Placental abruption
- D. Erythroblastosis fetalis
Correct answer: A
Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.
5. 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.
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