a nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding which of the following findings shoul
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ATI Capstone Maternal Newborn Assessment Quizlet

1. A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.

2. A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?

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.

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?

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 newborn delivered at 41 weeks of gestation is showing signs of postmaturity. Which of the following findings is an indication of fetal postmaturity?

Correct answer: C

Rationale: The correct answer is C: 'Thin with loose skin.' Postmature newborns are typically thin with loose skin due to prolonged gestation. This may result from placental insufficiency, leading to reduced subcutaneous fat stores. Choices A, B, and D are incorrect. Soft, flexible ear cartilage (choice A) is a normal finding in newborns. Smooth soles without creases (choice B) are also typical in newborns. Vernix caseosa covering the body (choice D) is a protective, waxy coating found on newborns, which may be present in postmature infants as well.

5. 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?

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.

Similar Questions

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A nurse is teaching a client who is at 20 weeks of gestation about the glucose tolerance test. Which of the following instructions should the nurse include?
A client who is postpartum reports abdominal cramping during breastfeeding. Which of the following actions should the nurse take?
A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?
A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?

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