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Maternal Newborn ATI Study Guide Maternal Newborn ATI A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse’s priori... ty? **Amount of lochia** - When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? **Apply sacral counterpressure** - Sacral counterpressure assists in relieving back labor pain related to fetal posterior position. A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? **Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck by lifting the newborn’s chin. Cleanse the skin around the newborn’s umbilical cord stump. Wash the newborn’s legs and feet. Clean the newborn’s diaper area.** - Use a head to toe, clean to dirty approach when washing a newborn. A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take? **Take photos of the newborn to give to the parents.** - The nurse should create a memory box that includes mementos of the newborn (ex: photos, the newborn’s ID bands, the newborn’s hat, & the newborn’s blanket). A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? **Biophysical profile** - A positive contraction stress test indicates that further evaluation of the fetus is necessary (baby’s heart slowed or showed abnormality during contraction). A biophysical profile will provide further evaluation with real-time ultrasound. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? **Platelets 50,000/mm3** - A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? **Minimal arm recoil** - The nurse should expect a newborn who was born at 26 weeks gestation to have decreased muscular tone, or minimal arm recoil. A nurse is assessing a newborn following circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? **Chin quivering** - Behavioral responses to a newborn’s pain include facial expressions (ex: chin quivering, grimacing, & furrowing of the brow). A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? **Vomiting** - Expected clinical manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, & vomiting. These usually last 2 days. A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? **Remove all clothing from the newborn except the diaper.** - The nurse should remove all of the newborn’s clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? **Protect the client’s head and feet from cold air.** - Protecting the client’s head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Hispanic practices also include delaying bathing for 14 days, bed rest for 3 days, and drinking warm beverages following delivery. A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? **Perform Leopold maneuvers.** - The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer. A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hours. Which of the following statements should the nurse make? **”Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.”** - Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for the progression of labor. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? **Massage the client’s fundus.** - The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client’s fundus to expel clots and promote contractions. A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions? **Bisacodyl rectal suppository daily as needed for constipation** - The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection. A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client’s head to one side, which of the following actions should the nurse take immediately after the seizure? **Administer oxygen via a nonrebreather mask.** - When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to mother and fetus. A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? **”You can miss your period for several other reasons. Describe your typical menstrual cycle.”** - Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client’s menstrual cycle to determine other necessary interventions. A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? **”You should get a 2-hour oral glucose tolerance test in 6-12 weeks.”** - The nurse should instruct the client to get 2-hour oral glucose tolerance test 6-12 weeks postpartum and every 3 years to screen for type 2 diabetes. The nurse should instruct the client that blood glucose levels return to the expected reference range after childbirth. Therefore, the client does not need to monitor her blood glucose levels or continue the insulin at home. A nurse on an antepartum unit is caring for 4 clients. Which of the following clients should the nurse identify as the priority? **A client who is at 34 weeks gestation and reports epigastric pain** - Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. - - - - - - - - - Continued [Show More]

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