a nurse is caring for a client who is at 15 weeks of gestation is rh negative and has just had an amniocentesis which of the following interventions i
Logo

Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Correct answer: D

Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.

2. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Correct answer: C

Rationale: The correct answer is C. When a client with preeclampsia is receiving magnesium sulfate via continuous IV infusion, it is crucial to monitor the fetal heart rate (FHR) continuously. Magnesium sulfate is given to prevent seizures and is considered a high-alert medication that requires close monitoring, especially of FHR and uterine contractions. Monitoring the client's blood pressure every hour, as in choice A, is important but not as crucial as continuous FHR monitoring. Restricting the total hourly intake to 200 mL, as in choice B, is not a relevant intervention for a client receiving magnesium sulfate. Administering protamine sulfate for manifestations of toxicity, as in choice D, is incorrect as protamine sulfate is not the antidote for magnesium sulfate toxicity.

3. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

Correct answer: A

Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.

4. During an assessment of a newborn following a vacuum-assisted delivery, which of the following findings should the healthcare provider be informed about?

Correct answer: A

Rationale: Poor sucking in a newborn following a vacuum-assisted delivery could indicate potential issues with feeding or neurological function, which need to be promptly addressed by the healthcare provider to ensure the well-being of the infant. It is essential for the healthcare provider to be informed about poor sucking to facilitate further evaluation and intervention. Choices B, C, and D are not typically associated with vacuum-assisted delivery and do not pose immediate concerns that require urgent attention.

5. A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. A continuous high-pitched cry is a characteristic sign of neonatal abstinence syndrome, indicating withdrawal from drugs. Choices A, C, and D are incorrect because decreased muscle tone, sleeping for 2 to 3 hours after a feeding, and mild tremors when disturbed are not specific indicators of neonatal abstinence syndrome.

Similar Questions

A healthcare professional is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the healthcare professional's priority?
A healthcare provider is instructing a client who is taking an oral contraceptive about manifestations to report. Which of the following manifestations should the healthcare provider include?
A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?
A client is scheduled for a cesarean birth based on fetal lung maturity. Which finding indicates that the fetal lungs are mature?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses