A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to

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ATI Maternal Newborn Proctored Questions

Question 1 of 5

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to

Correct Answer: A

Rationale: The correct answer is A because the newborn's head crowning indicates imminent delivery, and the client's urge to push aligns with the natural progression of labor. By encouraging the client to push, the nurse facilitates the safe and timely delivery of the baby. Panting (choice B) or slow-paced breathing (choice C) may not be effective in this advanced stage of labor. Taking a deep cleansing breath (choice D) can delay the delivery and is not recommended when the baby is crowning.

Question 2 of 5

The nurse would classify a newborn delivered at 39 weeks' gestation, weighing 2400 g ( 5.0 lbs) as being:

Correct Answer: B

Rationale: The correct answer is B: Small-for-gestational age. A newborn delivered at 39 weeks' gestation and weighing 2400g is considered small-for-gestational age because the weight is below the 10th percentile for the gestational age. This indicates intrauterine growth restriction. Preterm and immature (choice A) would not apply as the baby was delivered at term. Average-for-gestational age (choice C) would not be accurate as the baby's weight is below the normal range for that gestational age. Choice D is also incorrect as the baby is not within the average weight range for the gestational age.

Question 3 of 5

The nurse should designate the highest priority health outcomes to be:

Correct Answer: A

Rationale: The correct answer is A because adequate oxygenation is a critical health outcome necessary for cellular function and overall well-being. Without sufficient oxygenation, other bodily functions can be compromised. Stable body temperature (B) is important but not as immediately life-threatening as inadequate oxygenation. Weight gain (C) is not a priority health outcome in this scenario. Heart rate recovery (D) is important but ensuring adequate oxygenation takes precedence in this case.

Question 4 of 5

Which teaching is most critical for a mother with gestational diabetes?

Correct Answer: B

Rationale: The correct answer is B because monitoring blood glucose levels is crucial in managing gestational diabetes to prevent complications for both the mother and baby. By regularly monitoring blood glucose levels, the mother can adjust her diet and insulin intake accordingly to maintain optimal blood sugar levels. This helps in reducing the risk of adverse outcomes such as macrosomia and neonatal hypoglycemia. Choice A is incorrect because while a balanced diet is important, focusing solely on high-protein intake may not address the specific needs of gestational diabetes management. Choice C is also important for overall health, but blood glucose monitoring takes precedence in managing gestational diabetes. Choice D is incorrect as monitoring for preterm labor signs is important in pregnancy but is not directly related to managing gestational diabetes.

Question 5 of 5

What is the most critical sign of fetal distress during labor?

Correct Answer: D

Rationale: The correct answer is D: Late decelerations in fetal heart rate. Late decelerations indicate uteroplacental insufficiency, where the fetus is not receiving enough oxygen during contractions. This is critical as it can lead to fetal hypoxia and acidosis, posing a risk to the baby's well-being. Early decelerations (C) are generally benign and result from head compression during contractions. Accelerations (A) are a reassuring sign indicating fetal well-being. Decreased variability (B) can be concerning but is not as critical as late decelerations in indicating fetal distress.

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