ATI LPN
PN ATI Capstone Maternal Newborn Questions
Question 1 of 5
A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B: Nasal flaring. Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical finding that requires immediate attention from the healthcare provider. It can indicate that the newborn is having difficulty breathing and may be struggling to maintain adequate oxygenation. Option A (axillary temperature 36.5°C) is within the normal range for a newborn and does not indicate any immediate concerns. Option C (heart rate 158/min) can be normal for a newborn shortly after birth and may not be alarming unless accompanied by other signs of distress. Option D (one void since birth) can be a normal finding in a newborn within the first 24 hours as they are still transitioning to regular voiding patterns. Educationally, it is important for nurses to understand the significance of subtle signs like nasal flaring in newborn assessment. This knowledge helps in early identification of potential problems and prompt intervention, ensuring the well-being of the newborn. Nurses play a crucial role in monitoring newborns closely for any deviations from normal and advocating for timely medical attention when needed.
Question 2 of 5
A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Abruptio placentae. Abruptio placentae is the premature separation of the placenta from the uterine wall before delivery, which can result in continuous abdominal pain and vaginal bleeding. This condition is associated with maternal cocaine use due to its vasoconstrictive effects, leading to poor placental perfusion and potential placental abruption. Option B) Hydatidiform mole is incorrect as it presents with symptoms such as vaginal bleeding but is not typically associated with cocaine use. Option C) Preterm labor is unlikely in this case as the symptoms described are more indicative of a placental issue rather than early labor. Option D) Placenta previa, where the placenta partially or completely covers the cervix, would typically present with painless vaginal bleeding, unlike the continuous abdominal pain described in the scenario. Educationally, understanding these complications in pregnancy, their risk factors, and associated symptoms is crucial for nurses caring for pregnant clients. Recognizing the signs of abruptio placentae in a client with a history of cocaine use can prompt quick intervention to ensure the well-being of both the mother and the baby.
Question 3 of 5
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D) Administer the injection in the client's abdomen. When administering heparin subcutaneously, it is recommended to inject into the abdomen because it provides a larger area for absorption and reduces the risk of tissue damage or hematoma formation. This area has a higher percentage of subcutaneous fat, which helps with medication absorption and minimizes the risk of bleeding or bruising. Option A is incorrect because aspirin is not indicated for deep-vein thrombosis and can increase the risk of bleeding when taken with heparin. Option B is incorrect as massaging the injection site can lead to tissue damage or bruising. Option C is incorrect because heparin is safe to use while breastfeeding, so there is no need to restrict breastfeeding while on this medication. In an educational context, it is crucial for nurses to understand the appropriate administration techniques for medications like heparin to ensure optimal patient outcomes and prevent complications. Proper technique not only enhances medication effectiveness but also promotes patient safety and comfort. Nurses must be knowledgeable about the rationale behind each technique to provide evidence-based care to their patients.
Question 4 of 5
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: In this scenario, selecting option C) Discontinue the infusion of oxytocin as the first action is crucial due to the presence of recurrent variable decelerations of the fetal heart rate (FHR). Oxytocin, a uterotonic agent, can lead to uterine hyperstimulation, which may result in fetal distress manifested by variable decelerations. Discontinuing the oxytocin infusion helps to alleviate this stress on the fetus and allows for the reevaluation of the situation. Option A) Prepare the equipment necessary to initiate an amnioinfusion is not the priority in this situation as addressing the cause of the variable decelerations by discontinuing oxytocin takes precedence over other interventions. Administering oxygen at 10 L/min via a nonrebreather face mask (option B) is important in cases of fetal distress, but in this case, addressing the underlying cause by discontinuing oxytocin is the primary step. Placing the client in a left lateral position (option D) is beneficial for optimizing maternal and fetal oxygenation but should come after addressing the oxytocin infusion to manage the variable decelerations effectively. Educationally, understanding the effects of oxytocin on fetal well-being and the appropriate responses to fetal distress during labor are essential for nurses caring for laboring clients. Recognizing the significance of timely interventions based on fetal heart rate patterns is crucial in ensuring positive maternal and neonatal outcomes.
Question 5 of 5
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: In this scenario, option B, initiating seizure precautions for the client, is the correct action for the nurse to take when admitting a client at 33 weeks of gestation with preeclampsia and severe features. Preeclampsia with severe features increases the risk of eclampsia, a life-threatening condition characterized by seizures. Initiating seizure precautions, such as padding the client's bed rails, maintaining a safe environment, and having emergency medications readily available, is essential in preventing and managing potential seizures. Option A, restricting protein intake to less than 40 g/day, is incorrect because protein restriction is not a standard treatment for preeclampsia. In fact, adequate protein intake is important for supporting maternal and fetal health during pregnancy. Option C, initiating an infusion of 0.9% sodium chloride at 150 mL/hr, is incorrect as it does not directly address the immediate risk of seizures associated with severe preeclampsia. While IV fluids may be indicated for managing preeclampsia, the priority in this case is preventing seizures. Option D, encouraging the client to ambulate twice per day, is incorrect because ambulation may not be safe or appropriate for a client with severe preeclampsia, especially if there is a risk of seizures. Bed rest is often recommended for these clients to reduce the risk of complications. Educationally, understanding the priority interventions for clients with preeclampsia and recognizing the signs and symptoms of worsening conditions are crucial for nurses caring for pregnant clients. Prioritizing safety measures, such as seizure precautions, can help prevent adverse outcomes and promote optimal maternal and fetal health.