ATI RN
Needs of Maternal and Reproductive Health Clients Questions
Question 1 of 5
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
Correct Answer: A
Rationale: These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the silent is in a lateral position are also appropriate interventions.
Question 2 of 5
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
Correct Answer: D
Rationale: The correct answer is D) Urine output 90 ml/4 hours, indicating magnesium sulfate toxicity in a client with severe preeclampsia. Magnesium sulfate toxicity can lead to decreased urine output due to renal failure, a serious complication. This is a critical sign for the nurse to recognize and intervene promptly to prevent further harm to the client. Option A) Deep tendon reflexes 2+ is a normal finding and not indicative of magnesium sulfate toxicity. Option B) Blood pressure 140/90 is within normal range for a pregnant client with preeclampsia and does not specifically indicate magnesium sulfate toxicity. Option C) Respiratory rate 18/minute is also a normal finding and not a specific indicator of magnesium sulfate toxicity. In an educational context, understanding the signs and symptoms of magnesium sulfate toxicity is crucial for nurses caring for maternal and reproductive health clients. Recognizing these signs promptly can help prevent serious complications and ensure the best outcomes for both the mother and the baby. Regular assessments and knowledge of potential complications are essential in providing safe and effective care to these clients.
Question 3 of 5
The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client teaching plan?
Correct Answer: B
Rationale: The correct answer is B) Increase daily caloric intake is needed. During pregnancy, especially in the case of gestational diabetes, it is essential for the client to maintain stable blood sugar levels through a combination of proper nutrition and insulin management. Increasing daily caloric intake is important to support the nutritional needs of both the mother and the developing fetus. Option A) Insulin production is decreased during pregnancy is incorrect because in gestational diabetes, the body may become more resistant to insulin, leading to higher blood sugar levels that require proper management through external insulin administration. Option C) Injection requirements remain the same is incorrect because insulin requirements may change during pregnancy due to hormonal fluctuations and increased insulin resistance. The nurse should educate the client on potential adjustments needed based on blood sugar monitoring. Option D) Blood sugars need less monitoring in the first trimester is incorrect because blood sugar monitoring is crucial throughout the entire pregnancy, including the first trimester, to ensure optimal management of gestational diabetes and the well-being of both the mother and the baby. In an educational context, it is important for nurses to provide comprehensive and accurate information to clients with gestational diabetes to empower them to make informed decisions about their health and the health of their baby. Proper nutrition, insulin management, and monitoring are key components of managing gestational diabetes effectively.
Question 4 of 5
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is option A, which is to measure bilirubin levels using a transcutaneous bilirubinometer. This is the most appropriate initial step when observing a yellow tint to the skin in a newborn, as it helps in assessing for jaundice, a common condition in newborns due to the breakdown of red blood cells. Option B, reviewing maternal medical records for blood type and Rh factor, is not the immediate action required when assessing jaundice in a newborn. While maternal factors can contribute to neonatal jaundice, assessing bilirubin levels in the newborn is more crucial at this point. Option C, preparing the newborn for phototherapy, is premature without knowing the actual bilirubin levels. Phototherapy is a treatment for severe jaundice, but it should be based on bilirubin level results. Option D, evaluating cord results, is not the priority in this situation. While cord blood can provide some information, direct assessment of the newborn's bilirubin levels through a transcutaneous bilirubinometer is more immediate and accurate. Educationally, this question highlights the importance of prompt assessment and intervention in newborn care. Understanding the significance of jaundice in newborns and the appropriate steps to take is crucial for nurses working in maternal and newborn health settings. Early detection and management of jaundice can prevent complications and ensure optimal outcomes for the newborn.
Question 5 of 5
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the client's 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 to instruct the client to use deep breathing during contractions (Option D). Deep breathing techniques can help the client manage labor pain effectively by promoting relaxation, reducing stress, and increasing oxygen flow to the body and baby. It is a non-pharmacological method that can be safely used in conjunction with other pain relief interventions. Option A, discontinuing the Pitocin infusion, is incorrect because the client is only at 3 cm dilation and stopping the oxytocin could potentially slow down labor progress. Option B, medicating the client with an additional 1 mg of Stadol IV push, is inappropriate as the client was already medicated 30 minutes ago, and overmedication can lead to respiratory depression in the mother and newborn. Option C, notifying the healthcare provider, is not immediately necessary as the situation does not require urgent provider intervention. Educationally, it is crucial for nurses to be knowledgeable about non-pharmacological pain management strategies during labor and understand the appropriate timing and dosages of pain medications to ensure safe and effective care for maternal and reproductive health clients. Teaching clients coping techniques like deep breathing empowers them to participate actively in their care and enhances their birthing experience.