ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet Questions
Question 1 of 9
A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.
Question 2 of 9
A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?
Correct Answer: A
Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.
Question 3 of 9
A nurse is providing care to a client who is in active labor. The nurse observes variable decelerations in the fetal heart rate. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct action the nurse should take first when observing variable decelerations in the fetal heart rate is to reposition the client from side to side. Variable decelerations are often caused by umbilical cord compression, and repositioning the client can relieve pressure on the cord. Administering oxygen, increasing the IV infusion rate, and notifying the provider can be appropriate actions but repositioning the client takes priority in addressing variable decelerations.
Question 4 of 9
A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.
Question 5 of 9
A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.
Question 6 of 9
A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?
Correct Answer: D
Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.
Question 7 of 9
A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.
Question 8 of 9
A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: 'You should avoid consuming liquids with your meals.' This advice is essential because avoiding drinking liquids with meals can help prevent overdistension of the stomach, which can worsen nausea. Option A is incorrect because eating foods high in protein before bedtime may not directly address the issue of nausea and vomiting. Option C is incorrect as eating three large meals a day may exacerbate nausea due to overeating or having an empty stomach for an extended period. Option D is incorrect as consuming caffeine can actually worsen nausea in pregnant clients.
Question 9 of 9
A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?
Correct Answer: B
Rationale: The correct instruction for the nurse to provide is to advise the client to apply breast milk to the nipples after feedings. Breast milk has healing properties and can help soothe sore nipples. Option A is incorrect because avoiding the use of a breast pump does not directly address nipple soreness. Option C is incorrect as feeding the newborn less frequently can lead to engorgement and further complications. Option D is incorrect as using a nipple shield during feedings may not address the underlying issue of soreness and can sometimes even worsen the situation.