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
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ATI Capstone Maternal Newborn Assessment Quizlet

1. 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?

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.

2. A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?

Correct answer: B

Rationale: The correct answer is B. Calcium intake is crucial during pregnancy to support fetal bone development. The nurse should educate the client to increase their calcium intake. Choice A is incorrect because fetal movements are usually felt around 18-25 weeks, not at 12 weeks. Choice C is incorrect as exercise is generally encouraged during pregnancy, including the second trimester, as long as it is not high-impact or risky. Choice D is incorrect as folic acid intake is essential during pregnancy to prevent neural tube defects, and pregnant individuals are usually advised to increase their folic acid intake.

3. A client at 37 weeks of gestation is scheduled for a nonstress test. What information should the nurse include?

Correct answer: C

Rationale: The correct answer is C. Drinking orange juice before the nonstress test can increase fetal movement, which is essential for an accurate reading. Choice A is incorrect because oxytocin is not typically administered during a nonstress test. Choice B is incorrect as fasting is not required before this test. Choice D is incorrect as a full bladder is not necessary for a nonstress test.

4. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?

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.

5. 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.

Similar Questions

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 in the first trimester of pregnancy who is experiencing nausea is receiving teaching from a nurse. Which of the following instructions should the nurse include in the teaching?
A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?
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 nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?

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