ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?
- A. Contraction frequency of 2 minutes
- B. Contraction duration of 90 seconds
- C. Fetal heart rate of 150/min
- D. Urine output of 60 mL/hr
Correct answer: B
Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.
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 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 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.
5. 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.
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