ATI LPN
Maternal Newborn ATI Quizlet Questions
Question 1 of 9
A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition. Summary: - Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia. - Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus. - Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.
Question 2 of 9
During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?
Correct Answer: C
Rationale: During a Leopold maneuver, if the healthcare professional determines that the fetus is in an RSA position, it means the fetal back is on the right side, and the small parts are on the left side, indicating a breech presentation. Therefore, the correct answer is C: Breech. The other choices are incorrect because: A: Vertex refers to the head-first position. B: Shoulder presentation would involve feeling the shoulder first during the maneuver. D: Mentum presentation would involve feeling the chin first, which is not the case in an RSA position.
Question 3 of 9
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: Step-by-step rationale for why the correct answer is A: 1. Maternal/newborn blood group incompatibility can result in hemolytic disease of the newborn. 2. Hemolytic disease causes an increase in bilirubin levels, leading to jaundice. 3. Jaundice in this case is due to the breakdown of red blood cells and elevated unconjugated bilirubin levels. 4. Physiologic jaundice is a normal process in newborns and usually appears after the first 24 hours of life. 5. Absence of vitamin K would not directly cause jaundice. 6. Maternal cocaine abuse is not typically associated with neonatal jaundice. In summary, the correct answer is A because maternal/newborn blood group incompatibility can lead to hemolytic disease and subsequent jaundice, while the other choices are not directly related to neonatal jaundice.
Question 4 of 9
When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?
Correct Answer: A
Rationale: The correct answer is A: Perform a sharp hand clap near the infant. This action elicits the Moro reflex by stimulating the startle response. The Moro reflex involves the baby's arms spreading out and then coming back in when they feel like they are falling. This reflex helps in assessing the baby's neurological development. Choices B, C, and D do not specifically target the Moro reflex and may elicit other reflexes or responses. Holding the newborn vertically (B) may trigger the stepping reflex, placing a finger at the base of the toes (C) may provoke the Babinski reflex, and turning the newborn's head (D) may elicit the tonic neck reflex.
Question 5 of 9
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
Correct Answer: D
Rationale: The correct answer is D: Fetal position is persistent occiput posterior. This position, where the baby's head is facing the mother's abdomen instead of her back, can lead to severe backache and difficulty during labor due to increased pressure on the mother's spine. This malposition can impede the progress of labor and cause prolonged labor. Explanation of incorrect choices: A: Fetal attitude in general flexion is a normal position and not typically associated with severe backache. B: Fetal lie being longitudinal refers to the baby's position in relation to the mother's spine and is not directly related to backache. C: Maternal pelvis being gynecoid is a favorable shape for childbirth and is unlikely to cause severe backache during labor.
Question 6 of 9
A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
Correct Answer: D
Rationale: The correct answer is D, abruptio placentae. This condition is characterized by sudden onset of continuous abdominal pain and vaginal bleeding, common at 36 weeks gestation with pregnancy-induced hypertension. It occurs when the placenta prematurely separates from the uterine wall. Placenta previa (A) presents painless bleeding, prolapsed cord (B) involves cord presenting before the fetus, and incompetent cervix (C) leads to painless dilation of the cervix. Thus, abruptio placentae is the most likely complication in this scenario.
Question 7 of 9
A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition. Summary: - Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia. - Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus. - Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.
Question 8 of 9
A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?
Correct Answer: B
Rationale: The correct answer is B because Kegel exercises help strengthen the pelvic floor muscles, which can aid in pelvic muscle stretching during birth. This can potentially reduce the risk of pelvic floor dysfunction postpartum. A is incorrect because Kegel exercises do not directly prevent constipation. C is incorrect because while Kegel exercises may indirectly help with backaches by improving pelvic floor muscle support, they are not specifically targeted for backache relief. D is incorrect as Kegel exercises do not prevent stretch marks, as stretch marks are related to skin elasticity rather than muscle tone.
Question 9 of 9
A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is a sign that precedes labor as the body may experience a burst of energy known as the "nesting instinct." This surge can occur as the body prepares for the upcoming physical demands of labor. A: Decreased vaginal discharge is not a sign of impending labor; in fact, there may be an increase in vaginal discharge as the body prepares for childbirth. C: Urinary retention is not a sign of impending labor and can be a symptom of other issues such as a urinary tract infection. D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor approaching; weight fluctuations during pregnancy are common and can vary based on various factors.