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 pr
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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?

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 nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: A respiratory rate of 70/min in a newborn is above the expected range and may indicate respiratory distress, which should be reported to the provider. Choice B, vernix caseosa covering the skin, is a normal finding in newborns and does not require reporting. Choice C, milia on the bridge of the nose, is also a common finding in newborns and does not require immediate reporting. Choice D, acrocyanosis of the extremities, is a common finding within the first few hours of life in newborns and typically resolves on its own, so it does not need to be reported.

3. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.

4. A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for a client who is postpartum and had a cesarean birth is to not lift anything heavier than her newborn. This precaution is crucial to prevent injury to the healing incision site and allow for proper recovery. Choice A is incorrect as it implies resuming abdominal exercises in 2 weeks, which may strain the incision area. Choice C is incorrect because the client should wait longer than 1 week before driving to ensure they can perform emergency maneuvers if needed. Choice D is incorrect as resuming sexual activity in 2 weeks may put strain on the healing tissues and increase the risk of complications.

5. 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.

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