ATI LPN
PN ATI Capstone Maternal Newborn Questions
Question 1 of 9
A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress.
Question 2 of 9
A laboring client's membranes have just ruptured. What is the nurse's next action?
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
Question 3 of 9
A nurse is providing teaching to a client who is 32 weeks pregnant and has a diagnosis of placenta previa. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: Clients with placenta previa are at increased risk for bleeding and preterm labor. They should limit physical activity, monitor fetal movements, and notify their provider if they experience any contractions or signs of labor.
Question 4 of 9
A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It results from trauma during birth and typically resolves on its own.
Question 5 of 9
A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?
Correct Answer: D
Rationale: Leaving a baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash.
Question 6 of 9
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 nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Aspirin is contraindicated for clients on heparin due to increased bleeding risk.
Question 7 of 9
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
Correct Answer: D
Rationale: Calcium is vital during pregnancy for fetal bone development and to prevent maternal bone loss. The recommended daily intake should be increased to support these needs.
Question 8 of 9
A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?
Correct Answer: A
Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy.
Question 9 of 9
A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
Correct Answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void, which will allow the uterus to return to midline and become firm.