ATI RN
Maternal Newborn Practice Questions Questions
Question 1 of 5
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?
Correct Answer: B
Rationale: In this scenario, option B, which is a fetal heart rate of 180 beats/minute, indicates the need to contact the healthcare provider immediately. A fetal heart rate of 180 beats/minute is considered tachycardia and could be a sign of fetal distress, requiring urgent medical attention to assess the well-being of the baby. Option A, a hemoglobin of 11 g/dL, is within the normal range for a pregnant woman and does not indicate an immediate need for intervention. Option C, a maternal pulse rate of 85 beats/minute, is also within the normal range for an adult and does not raise immediate concerns. Option D, a white blood cell count of 12,000 mm3, could indicate an infection or inflammation in the body, but it is not as urgent as a fetal heart rate indicating distress. In an educational context, it is crucial for nurses to understand the significance of various assessment findings during pregnancy and childbirth. Recognizing abnormal values and knowing when to escalate concerns to the healthcare provider is essential for ensuring the safety and well-being of both the mother and the baby. This case highlights the importance of prompt action in response to abnormal fetal heart rate readings.
Question 2 of 5
The nurse is caring for a client in active labor with late decelerations on the monitor. What is the priority nursing intervention?
Correct Answer: A
Rationale: In the scenario presented, the priority nursing intervention when caring for a client in active labor with late decelerations on the monitor is to reposition the client to her side (Option A). This intervention is crucial as it helps improve placental perfusion by alleviating pressure on the vena cava and aorta, thus enhancing fetal oxygenation. Repositioning the client is effective in addressing the underlying cause of late decelerations, which is often due to compression of the umbilical cord or reduced blood flow to the placenta during contractions. By changing the client's position, the nurse can potentially improve blood flow to the placenta, thereby promoting better fetal oxygenation and reducing the risk of fetal distress. Administering IV fluids (Option B) may be important in certain situations to maintain hydration and support maternal blood pressure, but it is not the priority when late decelerations are observed. Applying oxygen via a face mask (Option C) can be beneficial in cases of fetal distress, but repositioning the client takes precedence in this scenario. Notifying the healthcare provider (Option D) is important, but it is not the immediate priority when interventions that can directly impact fetal oxygenation, like repositioning, are available to the nurse. In maternal newborn care, quick and appropriate actions can significantly influence maternal and fetal outcomes, making understanding and implementing priority interventions crucial for nurses in these situations.
Question 3 of 5
The nurse is performing an assessment of a postpartum client. Which finding requires immediate action?
Correct Answer: B
Rationale: In the postpartum period, foul-smelling lochia is indicative of a possible infection, specifically endometritis, which can lead to serious complications if not promptly addressed. Therefore, this finding requires immediate action to prevent further health issues for the mother. Option A, a temperature of 100.4°F, is elevated but may not necessarily indicate an immediate concern as it could be within the normal range for the postpartum period. However, close monitoring is still necessary. Option C, a firm and midline fundus, is actually a normal finding indicating proper uterine involution. This finding does not require immediate action. Option D, breast tenderness on palpation, is a common finding in postpartum women due to engorgement or breastfeeding. While discomfort should be addressed, it does not pose an immediate threat to the client's health. Educationally, this question emphasizes the importance of recognizing abnormal postpartum findings and prioritizing interventions based on the urgency of the situation to ensure optimal maternal outcomes. It highlights the need for nurses to be vigilant in their assessments and prompt in their responses to deviations from the expected postpartum course.
Question 4 of 5
The nurse is caring for a client with severe preeclampsia. What finding would indicate magnesium sulfate toxicity?
Correct Answer: B
Rationale: In the context of caring for a client with severe preeclampsia, magnesium sulfate is often used to prevent seizures. Therefore, monitoring for signs of magnesium sulfate toxicity is crucial. Option B, a respiratory rate of 10 breaths per minute, indicates magnesium sulfate toxicity as it is a central nervous system depressant and can lead to respiratory depression at toxic levels. This finding is a critical indicator of impending magnesium sulfate toxicity and requires immediate intervention. Option A, increased deep tendon reflexes, is actually a sign of magnesium deficiency rather than toxicity. Magnesium sulfate usually dampens reflexes, so an increase would not be indicative of toxicity. Option C, urine output of 50 mL/hour, is generally considered a normal urine output and is not specific to magnesium sulfate toxicity. Option D, a blood pressure of 160/110 mmHg, is a common finding in preeclampsia but is not a specific indicator of magnesium sulfate toxicity. Educationally, understanding the signs of magnesium sulfate toxicity is essential for nurses caring for pregnant clients with preeclampsia. It highlights the importance of close monitoring and prompt recognition of adverse effects to ensure the safety of both the mother and the baby.
Question 5 of 5
The nurse is educating a client about kick counts. What instruction is most appropriate?
Correct Answer: C
Rationale: In maternal newborn care, educating clients about kick counts is crucial for monitoring fetal well-being. The most appropriate instruction is option C: Count 10 fetal movements over 2 hours. This is the correct answer because it aligns with current guidelines recommending daily kick counts to assess fetal activity, with the expectation of feeling at least 10 movements within a 2-hour period. This frequency allows for regular monitoring of fetal health and prompt identification of any potential issues. Option A is incorrect as performing kick counts only once a week may not provide timely information about changes in fetal activity that could indicate distress. Option B is also inaccurate as lying on the back for prolonged periods can decrease blood flow to the uterus and should be avoided during pregnancy, especially in the third trimester. Option D is incorrect because kick counts should ideally begin earlier in the third trimester, around 28 weeks, rather than waiting until 36 weeks. Starting at 36 weeks may delay the detection of potential problems that could arise earlier. Educationally, understanding the rationale behind kick counts is vital for pregnant individuals to actively participate in monitoring their baby's movements and promptly report any concerns to their healthcare provider. Regular kick counts empower expectant mothers to be proactive in ensuring the well-being of their baby and can lead to timely interventions if issues arise.