ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,317 grams), weights 7 lbs. (3,175 grams) today.
Correct Answer: B
Rationale: In this scenario, option B, "Inform and assure the mother that this is a normal weight loss," is the correct answer. It is crucial for the nurse to educate the mother that it is normal for newborns to lose weight in the first few days of life. This initial weight loss is primarily due to the loss of excess fluids and meconium. By reassuring the mother, the nurse can alleviate any concerns and prevent unnecessary anxiety. Option A, monitoring stool and urine output, while important for assessing hydration status, is not the priority in this situation. Option C, encouraging increased breastfeeding, may not be necessary and could potentially lead to overfeeding. Option D, notifying the healthcare provider, is not warranted at this stage as the weight loss is within the expected range for newborns. Educationally, this question highlights the importance of understanding normal newborn physiological changes and the role of the nurse in providing appropriate education and support to new mothers. By addressing common concerns and providing accurate information, nurses can empower parents to care for their newborns effectively.
Question 2 of 5
A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge.
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Continue prenatal vitamins with B12 while breastfeeding. This option is correct because as a lacto-ovo vegetarian, the mother may have an increased risk of vitamin B12 deficiency due to the absence of animal products in her diet. Continuing prenatal vitamins with B12 while breastfeeding ensures that both the mother and the infant receive an adequate amount of this essential nutrient crucial for neurological development. Option A) Avoid using lanolin-based nipple cream or ointment is incorrect as it does not directly address the nutritional needs of the mother and the infant. Option B) Offering iron-fortified supplemental formula daily is unnecessary if the mother is able to maintain a balanced diet that meets her and her infant's nutritional needs through breastfeeding. Option D) Weigh the baby weekly to evaluate the newborn's growth is important but not directly related to the specific nutritional guidance needed for a lacto-ovo vegetarian mother. Educationally, it is crucial for healthcare providers to understand the unique dietary requirements of different populations, such as lacto-ovo vegetarians, and to provide tailored guidance to support optimal health outcomes for both the mother and the infant. By explaining the rationale behind the correct answer, nurses can empower mothers to make informed decisions regarding their diet and breastfeeding practices.
Question 3 of 5
A client at 38-weeks gestation complaints of severe abdominal pain. Upon the nurse notes that the abdomen is rigid.
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Abruptio placenta. This condition involves the premature separation of the placenta from the uterine wall before delivery, leading to severe abdominal pain and a rigid abdomen due to internal bleeding and clot formation behind the placenta. Option A) Placenta previa is characterized by painless vaginal bleeding in the third trimester, not severe abdominal pain and rigidity. Option B) Oligohydramnios refers to low levels of amniotic fluid and is not typically associated with severe abdominal pain or rigidity. Option D) Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, presenting with fever, uterine tenderness, and foul-smelling amniotic fluid, rather than severe abdominal pain and rigidity. Educationally, understanding these differential diagnoses is crucial for nursing students or healthcare providers working in maternity care to accurately assess and manage pregnant clients experiencing abdominal pain. Recognizing the signs and symptoms of abruptio placenta is vital for prompt intervention to ensure the well-being of both the mother and the fetus.
Question 4 of 5
The nurse is performing a newborn assessment. Which symptoms if present in newborn, would indicate respiratory distress?
Correct Answer: C
Rationale: In newborn assessment, recognizing signs of respiratory distress is crucial for prompt intervention. Option C, "Flaring of the nares," is the correct answer indicating respiratory distress in a newborn. Nasal flaring is a common sign of increased work of breathing and inadequate oxygenation. It suggests the baby is struggling to get enough oxygen. Option A, "Abdominal breathing with synchronous chest movement," is incorrect as it describes a normal breathing pattern in newborns due to their immature respiratory system. Option B, "Shallow and irregular respirations," while abnormal, do not specifically indicate respiratory distress. Option D, "Respiratory rate of 50 breaths per minute," is within the normal range for a newborn. It is important to educate nurses that isolated respiratory rate alone may not always indicate distress; it must be interpreted in conjunction with other signs like nasal flaring, grunting, retracting, or cyanosis. Educationally, understanding these signs equips nurses to identify respiratory distress early, intervene promptly, and prevent potential complications in newborns. It is crucial for nurses working in maternity settings to be adept at recognizing these signs to ensure the well-being of neonates.
Question 5 of 5
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 stations. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first.
Correct Answer: D
Rationale: In this scenario, the most appropriate action for the nurse to implement first is to determine cervical dilation (Option D). This is crucial because the client was admitted in active labor, and any changes in the cervix dilation can indicate progress or abnormalities in the labor process. Monitoring the cervical dilation helps the nurse assess the stage of labor and make informed decisions regarding the client's care and potential interventions. Checking the pH of the vaginal fluid (Option A) is not the priority in this situation as it does not provide immediate information related to the client's current labor progress. Reviewing the fetal heart rate pattern (Option B) is essential but should come after assessing the cervix to ensure the progress of labor. Palpating the client's bladder (Option C) is important for assessing bladder fullness but is not as urgent as determining cervical dilation in this active labor situation. Educationally, understanding the significance of assessing cervical dilation in active labor is essential for nurses and healthcare providers involved in maternity care. It helps them make timely decisions, monitor labor progress, and provide appropriate care to ensure a safe delivery for the mother and baby. This rationale highlights the importance of prioritizing tasks based on the client's condition and the stage of labor.