ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Swaddle the newborn tightly
- B. Provide frequent tactile stimulation
- C. Position the newborn in a prone position
- D. Offer large feedings every 4 hours
Correct answer: A
Rationale: The correct action for the nurse to take when caring for a newborn with neonatal abstinence syndrome is to swaddle the newborn tightly. Swaddling helps to provide comfort and reduce irritability in these newborns. Choice B, providing frequent tactile stimulation, may exacerbate the symptoms of neonatal abstinence syndrome by overstimulating the newborn. Choice C, positioning the newborn in a prone position, is not recommended as it increases the risk of sudden infant death syndrome (SIDS). Choice D, offering large feedings every 4 hours, is not appropriate as newborns with neonatal abstinence syndrome may have feeding difficulties and need smaller, more frequent feedings.
2. A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?
- A. Avoid sitting for long periods of time.
- B. Apply a cold pack to the perineal area for the first 24 hours.
- C. Use a sitz bath once per week.
- D. Begin Kegel exercises after the first week.
Correct answer: B
Rationale: The correct statement to include in the teaching is to apply a cold pack to the perineal area for the first 24 hours. This helps reduce swelling and promote comfort, aiding in the healing process after an episiotomy. Option A is incorrect as it does not provide specific guidance on managing postpartum recovery. Option C is incorrect because using a sitz bath once per week may not be frequent enough for proper wound care. Option D is incorrect because beginning Kegel exercises immediately after delivery can put excessive strain on the perineal area, potentially hindering healing.
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 providing discharge teaching to a client who is postpartum and has a prescription for ibuprofen for perineal pain. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Take the medication only at bedtime.
- C. Take the medication with food.
- D. Take the medication with caffeine.
Correct answer: C
Rationale: The correct answer is C: 'Take the medication with food.' Ibuprofen can cause gastrointestinal upset, so it is essential for the client to take the medication with food to minimize this side effect. Choice A, 'Take the medication on an empty stomach,' is incorrect because ibuprofen should be taken with food to prevent stomach irritation. Choice B, 'Take the medication only at bedtime,' is incorrect as there is no specific timing requirement for ibuprofen administration related to bedtime. Choice D, 'Take the medication with caffeine,' is incorrect as there is no benefit in combining ibuprofen with caffeine, and caffeine could potentially worsen gastrointestinal side effects.
5. A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?
- A. Instruct the client to perform rapid, shallow breathing
- B. Prepare the client for an emergency cesarean birth
- C. Have the client perform pelvic tilts during contractions
- D. Apply counterpressure to the client's sacrum
Correct answer: A
Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.
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