The nurse is assessing a postpartum client. Which finding requires immediate intervention?

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Maternal Newborn ATI Quizlet Questions

Question 1 of 5

The nurse is assessing a postpartum client. Which finding requires immediate intervention?

Correct Answer: B

Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.

Question 2 of 5

The nurse is assessing a client in active labor with variable decelerations on the fetal monitor. What is the priority intervention?

Correct Answer: B

Rationale: The correct answer is B: Reposition the client. Variable decelerations can indicate umbilical cord compression. Repositioning the client can help relieve the compression, improving fetal oxygenation. Increasing oxytocin (A) could worsen the situation. Administering oxygen (C) may be needed but repositioning is the priority. Performing a vaginal examination (D) is not indicated for variable decelerations.

Question 3 of 5

The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?

Correct Answer: C

Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.

Question 4 of 5

The nurse is monitoring a client in active labor with ruptured membranes. What finding requires immediate action?

Correct Answer: C

Rationale: The correct answer is C: Fetal heart rate of 100 beats/minute. A fetal heart rate of 100 beats/minute is bradycardia, indicating fetal distress and requiring immediate action to prevent adverse outcomes. Contractions every 3-5 minutes are normal in active labor. A temperature of 100.4°F indicates a low-grade fever but is not an immediate concern unless it continues to rise. Clear amniotic fluid is a normal finding after membrane rupture and does not require immediate action. Therefore, monitoring and addressing the fetal heart rate abnormalities are crucial in this situation.

Question 5 of 5

A client at 30 weeks' gestation is receiving corticosteroids. What is the primary purpose of this therapy?

Correct Answer: B

Rationale: The correct answer is B: To enhance fetal lung maturity. Corticosteroids given to a client at 30 weeks' gestation help accelerate fetal lung maturation, reducing the risk of respiratory distress syndrome in the newborn. This therapy does not prevent preterm labor but rather prepares the baby's lungs for potential early delivery. It also does not directly impact maternal blood pressure or blood glucose levels. Therefore, the primary purpose of corticosteroid therapy in this scenario is to benefit the baby's lung development, making option B the correct choice.

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