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ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?
- A. Hyperbilirubinemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypothermia
Correct answer: B
Rationale: Newborns who are large for gestational age (LGA) are at risk for hypoglycemia due to increased insulin production. Hyperbilirubinemia (Choice A) is more commonly associated with ABO or Rh incompatibility. Hypercalcemia (Choice C) is not a common finding in LGA newborns. Hypothermia (Choice D) may occur in newborns who are small for gestational age (SGA) due to a lack of subcutaneous fat for insulation, but it is not typically associated with LGA newborns.
2. 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?
- A. Blood pressure 80/50 mm Hg
- B. Uterine contractions
- C. Urine output 150 mL in 2 hours
- D. Client reports cramping
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.
3. A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?
- A. Tachycardia
- B. Hyperreflexia
- C. Respiratory rate of 10/min
- D. Polyuria
Correct answer: C
Rationale: Corrected Rationale: Magnesium sulfate can cause respiratory depression, leading to a decreased respiratory rate. A respiratory rate of 10/min is abnormally low and indicates magnesium toxicity. Tachycardia (Choice A) is not typically associated with magnesium toxicity. Hyperreflexia (Choice B) is a common sign of magnesium toxicity. Polyuria (Choice D) is not a typical finding of magnesium toxicity.
4. A nurse is providing discharge teaching to a client who is postpartum and has a prescription for methylergonovine. The nurse should instruct the client to report which of the following adverse effects?
- A. Headache
- B. Diarrhea
- C. Nausea
- D. Increased vaginal bleeding
Correct answer: A
Rationale: The correct answer is A: Headache. Methylergonovine can cause vasoconstriction, leading to headaches. It is important for the client to report this adverse effect to the provider as it may indicate a serious complication. Choices B, C, and D are incorrect because methylergonovine is not typically associated with diarrhea, nausea, or increased vaginal bleeding as common adverse effects.
5. A nurse is assessing a client who is at 35 weeks of gestation and has suspected placenta previa. Which of the following findings should the nurse expect?
- A. Painless vaginal bleeding
- B. Severe abdominal pain
- C. Uterine contractions
- D. Increased fetal movement
Correct answer: A
Rationale: Correct. Placenta previa typically presents with painless vaginal bleeding as the placenta is located over or near the cervical opening. This bleeding occurs because the placental vessels are stretched and bleed easily. Severe abdominal pain (choice B) is not a typical finding in placenta previa. Uterine contractions (choice C) are more characteristic of preterm labor rather than placenta previa. Increased fetal movement (choice D) is not a specific finding associated with placenta previa.
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