RN ATI CAPSTONE MATERNAL NEWBORN/CAPSTONE RN ATI MATERNAL NEWBORN LATEST VERSION 2023-2024, Exams of Health sciences

Download RN ATI CAPSTONE MATERNAL NEWBORN/CAPSTONE RN ATI MATERNAL NEWBORN LATEST VERSION 2023-2024 and more Exams Health sciences in PDF only on Docsity! RN ATI CAPSTONE MATERNAL NEWBORN/CAPSTONE RN ATI MATERNAL NEWBORN LATEST VERSION 2023-2024 ALL 180 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+. A nurse is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provide? Glycosuria A nurse is reinforcing teaching with a client who is trying to become pregnant. Which of the following foods should the nurse recommend as the best source of folate? 1 cup cooked spinach A nurse is caring for a client who is in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take? Inject the medication into the client's vastus lateralis muscles. A nurse is collecting data from a 28-year-old client who is requesting a prescription for an oral contraceptive. Which of the following information in the client's history should the nurse identify as a contraindication for the use of oral contraceptives? Frequent headaches with visual changes. A nurse is reinforcing teaching about preventing urinary tract infections with a client who is at 25 weeks of gestation. Which of the following instructions should the nurse include? "You should empty your bladder before you go to bed at night." A nurse is reinforcing education about the prevention of newborn abduction with a client who recently delivered. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "An alarm will sound if someone removes my baby's safety device." A nurse is reinforcing teaching about a nonstress test with a client who is at 33 weeks of gestation. Which of the following statements should the nurse include? "You will press a button when you feel the baby move." A nurse on a postpartum unit is contributing to the discharge teaching plan for a client. Which of the following instructions should the nurse suggest for the plan? Use a firm mattress in the newborn's crib. A nurse is reinforcing teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching? "I will position the retainer clip at the level of the baby's armpits." As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape-like clusters. Alleviating lower back pain during the latent phase of labor - ANSWER-Counter- pressure applied to the client's sacral area during contractions. This lifts the fetal head away from the sacral nerves, which decreases pain. Preterm labor - which medication should the nurse plan to administer? - ANSWER- Betamethasone IM A glucocorticoid that stimulates fetal lung maturity and thereby prevents respiratory depression. Methylergonovine - ANSWER-An ergot alkaloid. For patients experiencing postpartum hemorrhage. Stimulates uterine contractions. Poractant alfa - ANSWER-A synthetic lung surfactant. Administer to a preterm newborn who is experiencing respiratory distress. Misoprostol - ANSWER-Stimulates uterine contractions for a client who is undergoing labor induction. Oligohydramnios - ANSWER-A volume of amniotic fluid less than 300 mL during the third trimester. Occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause this. What causes late decelerations? - ANSWER-Fetal hypoxemia due to insufficient placental perfusion. Treatment of late decelerations - ANSWER-Reposition the client, initiate oxygen, and increase the infusion rate of IVF to enhance placental perfusion. What causes early decelerations? - ANSWER-Fetal head compression. What causes variable decelerations? - ANSWER-Compression of the umbilical cord. Often occurs after ROM. Nagele's rule - ANSWER-Count back 3 months from the first day of the LMP, then add 7 days. Most accurate means of obtaining client's F&E status? - ANSWER-Daily weights! Placenta previa - ANSWER-The placenta implants in the lower part of uterus and obstructs the cervical os. Avoid vaginal examinations, which can cause tearing of the placenta and increased bleeding. What should you do if a client that is in labor has moderate bright red vaginal bleeding? - ANSWER-Obtain blood samples for baseline laboratory values (Hgb and Hct). The patient should be on strict pelvic rest (no vaginal exams or ultrasounds). Early manifestation of gestation HTN or pre-eclampsia - ANSWER-Blurred or double vision Swollen face Decreased urinary output Proteinuria Decreased fetal activity Fetal movement should cause accelerations in the FHR. When is a non-stress test determined to be non-reactive? - ANSWER-After 40 minutes of continuous monitoring without accelerations in the FHR despite vibroacoustic stimulation. Pre-eclampsia treatment - ANSWER-Magnesium sulfate Can expect feeling warmth all over body and sedation while infusing. Have calcium gluconate at bedside!! When should the nurse report BP in a patient with pre-eclampsia? - ANSWER-> 160/110 Signs of magnesium toxicity - ANSWER-Loss of deep tendon reflexes Respiratory rate <12 breaths/minute Muscle weakness Urine output and pre-eclampsia... - ANSWER-If output is <20 mL/hr, it can indicate inadequate renal perfusion. If patient is receiving magnesium sulfate, this increases the risk for toxicity developing. A decreased urinary output can also indicate a decrease in renal perfusion s/t worsening of the client's pre-eclampsia. How often should the client feel the fetus move each hour? - ANSWER-At least 3 times per hour Nursing instruction for client reporting constipation - ANSWER-Moderate physical activity, such as walking at least 30 minutes every day or swimming. Increases intestinal peristalsis, which can help alleviate constipation. DO NOT consume mineral oil because it can lead to severe cramping, diarrhea, fluid loss, and preterm contractions. Decrease red meat consumption because it is high in iron and contributes to constipation. Cervical cerclage - ANSWER-Used for incompetent cervix Prevents premature opening of the cervix during pregnancy. Can expect spotting for 1-2 days after placement. Do not resume sexual intercourse until provider gives approval at postop visit. Immediately go to a facility for evaluation if experience any manifestations of labor while in place. Administration of Rho(D) immune globulin - ANSWER-At 28 weeks of gestation and again within 72h if the newborn is Rh-positive. Mother is not immune against rubella... - ANSWER-Receive immunization after delivery Polyhydramnios - ANSWER-The presence of excessive amniotic fluid surrounding the unborn fetus. Expected findings: GI malformations and neurologic disorders in the fetus. Can be detected by a fundal height greater than expected for gestational age & increased weight gain in mother. Gestational HTN can cause... (re: amniotic fluid) - ANSWER-Oligohydramnios Placental abruption - ANSWER-The placenta separates from the wall of the uterus before birth. Mild - can expect minimal dark red vaginal bleeding. Expected finding. Can be caused by exposure to a cool environment, which causes vasoconstriction. Placing newborn skin-to-skin on mother helps stabilize temp. Newborn hypoglycemia - ANSWER-<60 mg/dL Typically, 40-50 mg/dL Rubella immunization & breastfeeding - ANSWER-OK. Live attenuated virus does not pass into breast milk. Rubella immunization & getting pregnant - ANSWER-Do not conceive for at least 1 month after receiving the vaccine. Can cause miscarriage, congenital anomalies, or death of the fetus. Cluster feeding - ANSWER-Feeding every hour for several hours in a row. Expected finding for breastfeeding newborns. Mom should follow newborn's cues and feed 8-12 times per day. Tonic neck reglex - ANSWER-Quickly and gently turn the newborn's head to one side when sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turn his head while the opposite arm and leg flex. This reflex persists for about 3-4 months. Rooting reflex - ANSWER-Touch the newborn's lip, cheek, or corner of the mouth. The newborn should turn toward that side and open his mouth. This reflex usually persists for 3-4 months, but can last for 1 year. Moro reflex - ANSWER-Hold the newborn in a semi-sitting position and allow the trunk and head to fall backward about 2.5 cm (1 in). The newborn should abduct and extend his arms symmetrically, and the fingers should fan out and form a "C" with the thumb and forefinger. This reflex is the strongest during the first 8 weeks and usually disappears in about 4-5 months. Babinski reflex - ANSWER-Stroke the bottom of the newborn's foot upward along the lateral edge, then along the ball of the foot with a finger. The newborn's toes should hyperextend while the big toe dorsiflexes. This reflex persists for about 1 year. Calcium gluconate - ANSWER-Given if magnesium sulfate toxicity occurs Expected findings of a full-term newborn - ANSWER-Symmetric rib cage Normal, smooth skin with good turgor and the presence of subcutaneous fat pockets Little to no vernix Sparse lanugo (on shoulders, pinna, and forehead) Lanugo - ANSWER-Fine, downy hair Abundant in preterm newborns Skin of postmature newborn (greater than 42 weeks of gestation) - ANSWER-Dry, cracked skin with a wrinkled appearance Terbutaline - ANSWER-A smooth muscle relaxant Adverse effects of oxytocin - ANSWER-Water intoxication (monitor urinary output) HTN (monitor BP) Cardiac dysrhythmias (monitor pulse) Signs of a cervical laceration - ANSWER-Bright red bleeding ... slow trickle, oozing or outright bleeding, and a firm fundus. Photometer - ANSWER-Monitors the lamp's energy when treating a newborn with elevated bilirubin levels. Erythromycin opthalmic ointment - ANSWER-Prevents gonorrheal or chlamydial infections that the newborn can contract during birth. Given to every newborn within 1-2 hours of delivery. First action following delivery - ANSWER-Place the newborn directly on the client's chest. The greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose, and can cause the reopening of the PDA. Placing the newborn directly on the client's chest will help maintain the newborn's temperature. Vitamin K - ANSWER-IM injection The newborn is at risk for coagulation deficits. Should be given within the first 2 hours of life. Instructions for bottle-feeding - ANSWER-- Run tap water for 2 minutes, then boil it for 1-2 minutes before mixing with the formula to decrease the risk of contamination. - Only keep unused prepared formula for 48 hours. - Do not dilute the ready-to-feed formula because the newborn will get full before consuming the appropriate amount of calories and nutrients. Deviated fundus to the right or left can indicate what? - ANSWER-A full bladder. Should assist the client to empty bladder to prevent uterine atony and excessive lochia. Uterine atony risk factors - ANSWER-- Magnesium sulfate infusion: it's a smooth muscle relaxant that can prevent adequate contraction of the uterus - Distended bladder: after birth, can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics. A distended bladder displaces the uterus and can prevent adequate contractions of the uterus. - Prolonger labor: can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting. - Large for gestational age or multifetal gestation: can lead to over-stretching of the uterus and prevent uterine contractions. Uterine atony - ANSWER-The uterus fails to contract after delivery, and can lead to postpartum hemorrhage. Contraction of the uterine muscles (think about how they go in 3 different directions) compresses the blood vessels and reduces flow, thereby increasing the likelihood of coagulation and preventing hemorrhage. Congenital hip dysplasia - ANSWER-Asymmetrical gluteal folds Limited abduction of one hip because the head of the femur might have slipped out of the acetabulum. Cephalhematoma - ANSWER-An egg-shaped edematous, bluish discoloration that does not cross the suture line of a neonate's head. Results from a collection of blood between the skull and periosteum. 1 - some flexion 2 - well-flexed Apgar reflex irritability - ANSWER-0 - none 1 - grimace 2 - really pissed off (cry, cough, sneeze) Apgar color - ANSWER-0 - blue, pale 1 - pink body with acrocyanosis 2 - completely pink Expected ranges of physical measurements - ANSWER-■ Weight - 2,500 to 4,000 g (5lb 8oz - 8lb 13oz) ■ Length - 45 to 55 cm (18 to 22 in) ■ Head circumference - 32 to 36.8 cm (12.6 to 14.5 in) ■ Chest circumference - 30 to 33 cm (12 to 13 in) Appropriate for gestational age (AGA) - ANSWER-Weight is between the 10th and 90th percentile Small for gestational age (SGA) - ANSWER-Weight is below the 10th percentile Large for gestational age (LGA) - ANSWER-Weight is above the 90th percentile Low birth weight (LBW) - ANSWER-Weight of 2,500g (5lb 8oz) or less at birth Term - ANSWER-Birth between the beginning of week 38 and prior to the end of 42 weeks of gestation Newborn RR/pattern - ANSWER-Normal: Increases from 30-60/min with short periods of apnea (<15 seconds) most frequently during REM sleep cycle. Not normal: Apnea >15 seconds Crackles and wheezing Grunting and nasal flaring Newborn HR - ANSWER-100-160 bpm with brief fluctutations above and below Auscultate apical pulse for 1 minute when sleeping (over apex at 4th/5th intercostal space, left midclavicular line) Document & report murmurs Newborn BP - ANSWER-60-80 systolic 40-50 diastolic Newborn temp - ANSWER-36.5° (97.7°) to 37.2° C ( 98.9°) axillary The newborn is at risk for hypothermia and hyperthermia until thermoregulation (ability to produce heat and maintain normal body temperature) stabilizes. If the newborn becomes chilled (cold stress), oxygen demands can increase and acidosis can occur. Anything above 37.5° (99.5°) can be an indication of sepsis Desired fetal position for delivery - ANSWER-Anterior occiput position If the fetus is in the occiput posterior position, what action should the nurse take? - ANSWER-Assist the client into the hands and knees position during contractions. Helps to relieve back pain and will enable the rotation of the fetus. When is it safe to have sex again after a c-section? - ANSWER-Once all vaginal bleeding has stopped and the incision has healed, which can take 2-6 weeks. HIGHLY recommended to wait until after 6-week follow-up. How long should a client avoid abdominal exercises after a c-section? - ANSWER- 4-6 weeks. What position should the client be placed in if experiencing hypovolemic shock? - ANSWER-Side-lying The new mother is focused on herself and meeting her basic needs. Also, much excitement about the newborn and the birth experience. Need to repeat information to ensure client understanding because unable to retain information s/t excitement and fatigue. Letting-go phase - ANSWER-Focuses on moving forward as a family with interchanging numbers. Appropriate time to discuss contraceptive options. Carboprost - ANSWER-Vasoconstrictor used for PPH Can cause HTN, fever, & diarrhea. Recommended weight gain for a woman who has a BMI WITHIN expected reference range - ANSWER-25-35 pounds Recommended weight gain for a woman who has a BMI ABOVE expected reference range - ANSWER-15-20 pounds Contraindications to oral contraceptives - ANSWER-Cholecystitis HTN Migraine headaches Position client should be in to increase placental circulation - ANSWER-Side-lying Avoids compression of the vena cava. Expected physical findings of a newborn - ANSWER-Creases over 2/3's of the soles of the feet Molding of the head Lanugo on the shoulders Risk factors for pre-eclampsia - ANSWER-Pre-existing HTN Renal disease Systemic lupus erythematosus Rheumatoid arthritis Pregestational diabetes mellitus Expected findings - nuchal cord - ANSWER-Bruising and petechiae over the face, head, and neck Clinical manifestation of hypoglycemia - ANSWER-Respiratory distress Abnormal cry Jitteriness Lethargy Poor feeding Apnea Seizures Hypothermia Hypotonia Why are late preterm newborns at an increased risk for hypoglycemia? - ANSWER- Decreased glycogen stores and immature insulin secretion Vitamin D intake during pregnancy - ANSWER-600 IU/day (same as when not pregnant!) Calcium intake during pregnancy - ANSWER-1,300 mg/day younger than 19 years 1,000 mg/day between 19 and 50 years (same as when not pregnant!) 1-hr glucose tolerance test: positive screening result - ANSWER-130-140 mg/dL Will then need to undergo a 3-hr glucose tolerance test to confirm if client has gestational diabetes mellitus a nurse in a clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? use an ultrasound stethoscope to listen to fetal heart tones. a nurse is caring for a client who is 18hr postpartum and has a fourth-degree perineal laceration. The client reports a pain rating of 4 on a scale from 0-10. Which of the following should the nurse take? (SATA) -Promote the use of witch hazel pads -Give the client ice packs -Have the client take a cool water sitz bath -Encourage the client to practice relation techniques A nurse is reinforcing teaching with a client who has a new prescription of medroxyprogesterone acetate injection for contraception. Which of the following statements by the client indicates understanding of the teaching? "I am likely to gain weight while taking this medication." A nurse is assisting with the care of a client who is in the active phase of the first stage of labor. Which of the following findings should the nurse report to the charge nurse? Green fluid from the vagina. A nurse is collecting data from a client who gave birth 18 hr ago. Which of the following findings should the nurse identify as an indication of a postpartum complication? Fundus is palpable at 2cm above the umbillicus. A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes? Intramuscular A nurse is collecting data from a client who is receiving magnesium sulfate. Which of the following feedings should the nurse report to the provider? Absent deep-tendon reflexes A nurse is reinforcing teaching with a client who is pregnant and will undergo a 1- hr oral glucose tolerance test. Which of the following instructions should the nurse include? Avoid caffeine the morning of the test A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings should the nurse identify as an indication of infection? WBC 35,000 /mm3 A nurse is caring for a 12-hr-old male newborn who was delivered from a breech position. Which of the following findings should the nurse report to the charge nurse? Skin appears jaundiced. A nurse is caring for a client following a cesarean birth. Which of the following actions should the nurse take to decrease the client's risk of developing thrombophlebitis? Have the client ambulate several times each day. Rheumatoid arthritis A nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend? Monitor intake and output A nurse is caring for a client who is 2 hr postpartum. The nurse locates the client's fundus 2 cm above the umbilicus, with displacement to the right of the midline, and notes it is boggy. The nurse should identify which of the following complications as the likely cause of these findings? Bladder distention A nurse is contributing to the plan of care for a client who has eclampsia. Which of the following interventions should the nurse identify and plan to include as the priority immediately following a seizure? Administer oxygen via facemask at 10L/min. A nurse is contributing to the plan of care for a client who is postpartum and follows kosher dietary laws. Which of the following indicates a meal the nurse should offer this client? Foods that avoid eating meat and dairy products together. A nurse is caring for a client who is postpartum and is receiving carboprost. Which of the following statements should the nurse identify as an indication that the client understand the purpose of this medication? "This medication will slow down my bleeding." A nurse is collecting data from a client who is primigravida and has hyperthyroidism. Which of the following findings should the nurse expect? Diaphoresis A nurse is collecting data from a client who is at 37 weeks of gestation. Which of the following findings should the nurse report to the provider? Blurred vision A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will report any drainage from my baby's umbilical cord." A nurse is reinforcing discharge teaching with a client who has mastitis of the left breast. Which of the following instructions should the nurse include? Pump the affected breast frequently A nurse is reinforcing teaching with a client who is at 8 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching? "I should expect to have a white vaginal discharge during pregnancy." A nurse is caring for a client who gave birth to a newborn who is large for gestation age (LGA) 16 hr ago. Which of the following findings should the nurse identify as a complication of the birth of a newborn who is LGA? Hemorrhage A nurse is collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider? respiratory rate 10/min A nurse in a postpartum unit is caring for a client who has endometritis and is 48 hr postpartum following a cesarean birth. Which of the following findings should the nurse anticipate? Heart rate 110/min A nurse is collecting data from the parent of a newborn immediately following birth. The parent states, "She is so tiny. We don't know how to pick her up without labor increasing rectal pressure transition phase pregestational type 1 diabetes I will continue taking my insulin if I experience nausea and vomiting" postpartum and has idiopathic thrombocytopenia purpura decreased platelet count 22 wk gestation, blotchy hyperpigmentation explain to the client this is an expected occurence teaching: hyperemisis gravidarum i will eat foods that appeal to my taste instead of trying to balance my meals PLACE IN ORDER Leopold maneuvers -palpate the fundus to identify the fetal part - determine location of the fetal back -palpate for the fetal part presenting at the inlet - identify the attitude of the head requesting epidural anesthesia for pain monitor the clients BP every 5 minutes following the first dose of anesthetic solution 2 hr postpartum, intervention Demonstrate to the client how to perform a newborn bath how to use bulb syringe to suction newborn secretions stop suction when the newborn's cry sounds clear carboprost adverse effect for postpartum hemorrhage hypertension teaching birth 2 hr ago about newborn safety "the person who comes to take my baby's pictures will be wearing a photo identification badge" teaching physiological changes, 10 wk gestation with BMI in range "I will likely need to use alternative positions for sexual intercourse" assessing fetal heart tones: where to assess the point of maximum intensity of the fetal heart left lower quadrant administer mag sulfate 2g/hr IV. Avail 20 g in 50 ml d5w, how many ml/hr 50 teaching about using car seat properly position the car seat rear-facing in the back seat of the vehicle 36 wk gestation, nonstress test "you will be offered orange juice to drink during the test" family planning clinic, contraindication to oral contraceptives -cholecystitis continue monitoring the client newborn delivered vaginally, tight nuchal cord petechiae over the head late preterm newborn, indication of hypoglycemia respiratory distress adolescent, levonorgesteral contraception "you should take the medication within 72 hr following unprotected sexual intercourse'' educational program for adolescents about nutrition third trimester consume three to four servings of dairy each day group of parents, newborn safety, indicates understanding i will dress my baby in flame-retardant clothing developing plan of care preeclampsia and receiving mag sulfate IV monitor FHR continously discharge teaching postpartum, clinical manifestation should monitor and report unilateral breast pain newborn transferred to nursery 30 min after delivery verify the newborn's identification difference between true and false labor contractions become stronger with walking LD unit, client states "my water just broke", nursing priorty begin FHR monitoring 24 week gestation reports daily mild headaches. Care plan recommend that the client perform conscious relaxtion techniques daily vag exam client in labor,fetal head posterior position, non pharmacological intervention counter-pressure