ATI RN
Needs of Maternal and Reproductive Health Clients Questions
Question 1 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.
Question 2 of 5
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings what actions the nurse implement.
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is option A) Notify the healthcare provider of the finding. This is the most appropriate response because a fundal height measurement that exceeds expected gestational age could indicate issues such as polyhydramnios, macrosomia, or incorrect gestational age assessment. Notifying the healthcare provider promptly allows for further assessment, monitoring, and potential intervention to ensure the well-being of both the mother and the twins. Option B) Documenting the finding in the medical record is important but not sufficient as the next course of action. While documentation is essential for continuity of care, the priority in this situation is to address the potential concerns raised by the fundal height measurement. Option C) Scheduling the client for a biophysical profile may be premature at this point as it is typically done to assess fetal well-being in high-risk pregnancies. Further assessment and guidance from the healthcare provider are needed before proceeding to this step. Option D) Requesting another nurse to measure the fundus is unnecessary as the issue lies not in the accuracy of the measurement but in the clinical significance of the measurement exceeding the expected value. Educationally, this question highlights the importance of recognizing abnormal findings in maternal health assessments and the significance of timely communication with the healthcare team to ensure appropriate management and care for the pregnant client and her twins. It reinforces the critical role of the nurse in advocating for the health and well-being of their clients by promptly reporting and acting on abnormal findings.
Question 3 of 5
The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client?
Correct Answer: D
Rationale: In the case of a laboring client who is GBS+ (Group B streptococcus), the immediate treatment indicated is the administration of antibiotics (Option D). This is because Group B streptococcus is a bacterium that can be passed to the newborn during labor and delivery, potentially causing serious infections such as pneumonia, sepsis, or meningitis. Administering antibiotics to the mother during labor can significantly reduce the risk of transmission to the newborn. Option A, administration of Pitocin, is used to induce or augment labor and is not directly related to the treatment of GBS infection. Option B, artificial rupture of the membrane, can be a part of the labor process but does not address the specific concern of GBS infection. Option C, amnioinfusion for the baby, is a procedure used to address issues such as low amniotic fluid levels and is not the immediate treatment for GBS infection in a laboring client. In an educational context, understanding the importance of timely administration of antibiotics in GBS+ laboring clients is crucial for nurses caring for maternal and reproductive health clients. This knowledge ensures the safety of both the mother and the newborn by preventing potential complications associated with GBS infection. Nurses must be able to recognize the significance of this intervention to provide optimal care and promote positive maternal and neonatal outcomes.
Question 4 of 5
The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: In this scenario, the correct intervention is to position the radiant warmer over the crib (Option A) first. This is crucial because the preterm infant is displaying signs of respiratory distress and decreased muscle tone, indicating a need for immediate thermal support to prevent further complications. Placing the infant under the radiant warmer will help maintain the infant's body temperature, which is vital for stabilizing their condition and preventing hypothermia. Assessing the infant's blood glucose level (Option B) is important but not the priority in this situation where respiratory distress and hypothermia are primary concerns. Nipple feeding 1 ounce 1% glucose in water (Option C) can wait until the infant's condition is stabilized. Placing the infant in a side-lying position (Option D) is not the most appropriate intervention given the presented symptoms. In an educational context, understanding the priority of interventions in neonatal care is crucial for nurses working in maternal and reproductive health. This scenario highlights the importance of prioritizing interventions based on the infant's immediate needs to ensure optimal outcomes in neonatal care.
Question 5 of 5
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Contraction duration of 100 seconds. Prolonged contractions can lead to uteroplacental insufficiency, reducing fetal oxygenation. If contractions last too long, there is not enough time for the placenta to replenish oxygen to the baby. This can result in fetal distress and compromise the well-being of the baby. Option A) Uterus soft would not be a reason to discontinue oxytocin as this is a normal finding during the initial stages of labor. Option C) Four contractions in 10 minutes could indicate tachysystole, which is a concern, but it is not as immediately dangerous as prolonged contractions. Option D) Early deceleration of fetal heart rate is concerning but may not necessarily warrant immediate discontinuation of oxytocin unless it persists or worsens. Educationally, this question highlights the importance of monitoring both maternal and fetal well-being during labor induction or augmentation. Understanding the implications of prolonged contractions on fetal oxygenation is crucial for safe maternal and neonatal outcomes.