While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

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Maternal Newborn ATI Proctored Exam Questions

Question 1 of 5

While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?

Correct Answer: A

Rationale: Correct Answer: A - Cover the newborn's eyes with an opaque eye mask while under the phototherapy light. Rationale: 1. Phototherapy light can cause eye damage, so covering the newborn's eyes with an opaque eye mask protects them. 2. Newborns' eyes are more sensitive to light, making eye protection crucial during phototherapy. Summary of Incorrect Choices: B: Keeping the newborn in a shirt won't protect the eyes from phototherapy light. C: Applying lotion can interfere with the effectiveness of phototherapy and may cause skin irritation. D: Turning and repositioning the newborn is important for comfort, but eye protection is the priority during phototherapy.

Question 2 of 5

A client in a family planning clinic requests oral contraceptives. Which of the following findings in the client's history should be recognized as contraindications to oral contraceptives? (Select all that apply.)

Correct Answer: D

Rationale: The correct answer is D: All of the above. Cholecystitis, hypertension, and migraine headaches are all contraindications to oral contraceptives. Cholecystitis can be exacerbated by oral contraceptives. Hypertension increases the risk of cardiovascular events with oral contraceptives. Migraine headaches, especially with aura, are associated with an increased risk of stroke when combined with oral contraceptives. Therefore, considering these risks, it is crucial to recognize these findings as contraindications to prescribing oral contraceptives.

Question 3 of 5

A client who is 12 hours postpartum has a fundus located two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Assist the client to the bathroom to void. This action can help promote uterine contractions by relieving bladder distention, which can cause the fundus to be displaced. Voiding can help the uterus return to its normal position and firmness. Placing the client in a side-lying position (A) may be helpful for fundal massage but addressing bladder distention is the priority. Obtaining a prescription for IV oxytocin (C) or administering methylergonovine (D) are not indicated as first-line interventions for a fundus located above the umbilicus postpartum.

Question 4 of 5

When developing an educational program for adolescents about nutrition during the third trimester of pregnancy, which of the following statements should be included?

Correct Answer: A

Rationale: The correct answer is A: Consume three to four servings of dairy each day. During the third trimester of pregnancy, calcium needs increase to support the baby's bone development. Dairy products are a rich source of calcium. Adolescents are still growing themselves, so adequate calcium intake is crucial for both the mother and baby. B: Increasing caloric intake by 600 to 700 calories is not specific to the third trimester and may lead to excessive weight gain, which can be harmful. C: Limiting sodium intake to less than 1 gram is not necessary during pregnancy, and some sodium is required for maintaining fluid balance. D: Increasing protein intake to 40 to 50 grams per day is important, but it is not specific to the third trimester and may vary based on individual needs.

Question 5 of 5

During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?

Correct Answer: B

Rationale: The correct answer, B: Counter-pressure, is the best nonpharmacological intervention for a client with a posterior fetal head position causing lower back pain. Counter-pressure applied to the sacrum can help alleviate discomfort by reducing pressure on the lower back and providing support during contractions. This technique can aid in rotating the baby's head to a more optimal position for delivery. Choice A: Back rub, may offer some comfort but may not specifically address the issue of lower back pain caused by the fetal position. Choice C: Playing music, and Choice D: Foot massage, are unlikely to provide direct relief for the client's specific discomfort related to the baby's posterior position.

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