ATI RN
Needs of Maternal and Reproductive Health Clients Questions
Question 1 of 5
A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is to encourage the client to pant-blow during contractions (Option A). Pant-blowing is a technique used during the second stage of labor to prevent rapid pushing, which can lead to maternal exhaustion, fetal distress, and perineal trauma. By encouraging the client to pant-blow, the nurse helps control the pushing efforts, allowing for controlled and effective pushing during contractions. Assisting the client to push with contractions (Option B) would not be appropriate in this case as the client is already pushing forcefully, and further pushing could lead to complications as mentioned earlier. Preparing for an immediate delivery (Option C) is premature at this stage since the client is only 7 cm dilated, and the fetus is at +1 station. It is essential to allow the labor to progress further before preparing for delivery. Notifying the healthcare provider (Option D) is not necessary at this moment as the situation is within the realm of normal labor progress. The nurse can manage the client's pushing technique effectively without the need for immediate provider intervention. Educationally, understanding the appropriate pushing techniques during labor is crucial for maternal and fetal well-being. Nurses need to be knowledgeable about guiding clients in effective pushing methods to ensure optimal outcomes during the childbirth process.
Question 2 of 5
The home health nurse visits a client who delivered a full-term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curl-like patches on the newborns oral mucous membranes. What action should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to implement is A) Discuss the need for medication to treat the curl-like oral patches. These white patches are indicative of thrush, a common fungal infection in newborns. Educating the mother about this condition and the need for appropriate medication is crucial to ensure the infant receives proper treatment. Option B) Suggest switching the infant's formula is incorrect as the issue is related to a fungal infection, not the formula. Changing the formula would not address the underlying problem. Option C) Assess the baby's blood glucose level is also incorrect in this context as the symptoms described do not suggest a need for blood glucose monitoring. The oral patches are more likely related to thrush. Option D) Reminding the mother not to put the baby to bed with a propped bottle is important for preventing ear infections but is not directly related to the oral mucous membrane patches observed on the newborn. Educationally, understanding common postnatal health issues like thrush in newborns is essential for nurses working in maternal and reproductive health. Proper assessment, education, and intervention can help ensure the well-being of both the mother and the newborn.
Question 3 of 5
The father of a 3-day old infant who is breastfeeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no appeared reason. What information is most important for the nurse to provide the father?
Correct Answer: C
Rationale: The correct answer is C) A fluctuation in hormones in the early postpartum period can cause mood changes. This response is most important for the nurse to provide the father because it educates him about the common phenomenon of postpartum mood changes due to hormonal fluctuations in new mothers. By understanding this, the father can be more empathetic and supportive towards his wife during this challenging time. Option A is incorrect because waiting for two weeks for a situation to improve could be detrimental to the mother's mental health if she is experiencing postpartum depression or anxiety. Option B is irrelevant to the situation described and does not address the mother's emotional well-being. Option D is incorrect as it suggests giving supplemental bottle feedings, which may not be necessary and could interfere with successful breastfeeding. In an educational context, it is crucial for healthcare providers to educate families about the physical and emotional changes that new mothers may experience postpartum. By understanding these changes, families can provide better support and seek appropriate help if needed to ensure the well-being of both the mother and the newborn.
Question 4 of 5
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
Correct Answer: D
Rationale: The correct action for the nurse to implement in this scenario is Option D: Instruct the client to use deep breathing during contractions. Deep breathing techniques can help the client manage pain and discomfort during labor without the need for additional pain medication. Option A: Discontinuing the Pitocin infusion is not necessary at this point as the client's cervical dilation is only 3 cm, and oxytocin is being used for labor augmentation. Option B: Administering additional Stadol IV push may lead to excessive sedation and respiratory depression, especially since the client was already medicated with Stadol and promethazine 30 minutes ago. Option C: Notifying the healthcare provider is not the priority in this situation since the client's condition does not warrant immediate medical intervention. Educationally, it is important for nurses to understand the appropriate pain management strategies during labor and to prioritize non-pharmacological interventions like deep breathing techniques before resorting to additional medications. Nurses need to assess the client's condition, consider the effects of previous medications, and provide holistic care that supports the client's comfort and well-being during labor.
Question 5 of 5
A newborn infant is receiving immunization prior discharge. Which action should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to implement is option B: Obtain signed consent from the mother for administration of the hepatitis B vaccine. This is the right choice because obtaining informed consent is a fundamental ethical and legal requirement before administering any vaccine, ensuring that the parent is aware of the benefits and risks associated with the vaccination. Option A is incorrect because administering rotavirus vaccine during diarrhea can be contraindicated due to the risk of exacerbating dehydration. Option C is also incorrect as DTaP is usually not given to newborns but rather at 2, 4, and 6 months of age. Option D is incorrect because the decision to immunize should not be left solely to the parent's discretion without proper education and guidance from healthcare providers. In an educational context, understanding the importance of informed consent in healthcare is crucial for nurses and other healthcare providers. It ensures that patients and their families actively participate in the decision-making process regarding their health and treatment, promoting autonomy and ethical care practices. Nurses play a key role in educating parents about the benefits of immunizations, addressing concerns, and obtaining consent to ensure the well-being of both the child and the community.