ATI RN
Maternal Newborn Nursing Practice Questions Questions
Question 1 of 5
What two steps of the CJMM are included in the assessment step of the nursing process?
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.
Question 2 of 5
The nurse is assessing a client diagnosed with placenta previa. Which findings should the nurse expect to note?
Correct Answer: C
Rationale: In the case of placenta previa, the correct finding the nurse should expect to note is bright red vaginal bleeding (Option C). This is because placenta previa involves the abnormal implantation of the placenta over or near the cervical os, which can lead to bleeding as the cervix begins to dilate in preparation for labor. This bleeding is typically painless and can be sudden and profuse. The other options are incorrect for the following reasons: A) Uterine rigidity: Uterine rigidity is not typically associated with placenta previa. It is more commonly seen in conditions like placental abruption. B) Severe abdominal pain: Severe abdominal pain is not a typical finding in placenta previa. It is more commonly associated with conditions like placental abruption or uterine rupture. D) Soft, relaxed, nontender uterus: In placenta previa, the uterus is typically soft, relaxed, and nontender. Uterine rigidity or tenderness would be more indicative of other complications. Educational context: Understanding the signs and symptoms of placenta previa is crucial for nurses caring for pregnant women. Recognizing these symptoms promptly can lead to early intervention and management, which is vital in ensuring the best possible outcomes for both the mother and the baby. Nurses need to be able to differentiate between placenta previa and other obstetric emergencies to provide appropriate care.
Question 3 of 5
The nurse is preparing a client for a nonstress test. What instruction is most appropriate?
Correct Answer: C
Rationale: The correct answer to the question, "The nurse is preparing a client for a nonstress test. What instruction is most appropriate?" is option C: "You will need to press a button each time you feel the baby move." This instruction is correct because during a nonstress test, the purpose is to monitor the baby's heart rate in response to its own movements. The mother is provided with a button to press when she feels the baby move, which allows the healthcare provider to correlate the fetal movements with changes in the baby's heart rate. This helps in assessing the baby's well-being and determining if there are any signs of distress. Option A, "You need to fast for 12 hours before the test," is incorrect because fasting is not required for a nonstress test. It is a non-invasive procedure that does not necessitate fasting. Option B, "You will be given medication to stimulate fetal movements," is incorrect because a nonstress test is designed to monitor the baby's own movements naturally, without the need for any external stimulation. Option D, "You must lie flat on your back during the test," is incorrect because during a nonstress test, the mother is usually in a comfortable position, such as reclining in a chair or on a bed, to promote fetal movement and maternal comfort. In an educational context, understanding the correct instructions for a nonstress test is crucial for nursing students and healthcare professionals working in maternal newborn care. It is essential to know the purpose of the test, the correct procedure to follow, and how to educate and support the mother undergoing the test to ensure accurate results and optimal maternal-fetal outcomes.
Question 4 of 5
The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
Correct Answer: B
Rationale: In the context of maternal newborn nursing and pharmacology, the correct answer to the question is option B: Blood pressure of 140/90 mmHg on two occasions. This finding confirms the diagnosis of gestational hypertension. Gestational hypertension is characterized by elevated blood pressure readings during pregnancy. A blood pressure reading of 140/90 mmHg or higher on two separate occasions after 20 weeks of gestation is indicative of gestational hypertension. Option A, proteinuria, is a symptom of preeclampsia, not gestational hypertension. While proteinuria can be present in some cases of gestational hypertension, it is not the defining diagnostic criterion for this condition. Option C, edema of the hands and feet, is a common symptom in pregnancy but is not specific to gestational hypertension. Edema alone is not sufficient to confirm the diagnosis of gestational hypertension. Option D, elevated blood glucose levels, is more indicative of gestational diabetes rather than gestational hypertension. Gestational diabetes is a separate condition characterized by high blood sugar levels during pregnancy. It is essential for nurses caring for pregnant clients to understand the diagnostic criteria for gestational hypertension to provide timely and appropriate care. Monitoring blood pressure levels regularly, especially after 20 weeks of gestation, is crucial in identifying and managing gestational hypertension to prevent adverse outcomes for both the mother and the baby.
Question 5 of 5
The nurse is caring for a client in labor with meconium-stained amniotic fluid. What is the priority action?
Correct Answer: C
Rationale: In the scenario of a client in labor with meconium-stained amniotic fluid, the priority action is to prepare for potential neonatal resuscitation (Option C). Meconium-stained amniotic fluid indicates potential fetal distress due to the presence of meconium, which can lead to respiratory complications if aspirated by the newborn during delivery. Therefore, being prepared for immediate neonatal resuscitation is crucial to address any respiratory distress or complications that may arise in the newborn. Administering oxygen to the mother (Option A) may be beneficial, but the priority is the well-being of the newborn in this situation. Notifying the healthcare provider (Option B) is important, but immediate action to address potential neonatal complications takes precedence. Increasing IV fluid rate (Option D) is not the priority when dealing with meconium-stained amniotic fluid; the focus should be on the newborn's respiratory status and immediate interventions if needed. In an educational context, understanding the implications of meconium-stained amniotic fluid on the newborn's health and the need for prompt neonatal resuscitation can help nurses provide effective and timely care in labor and delivery settings. Prioritizing actions based on the potential risks to the newborn's health is essential in maternal newborn nursing practice.