ATI Capstone Maternal Newborn
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 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 performing a blood collection via heel stick on a newborn for blood glucose monitoring. After washing her hands and donning gloves, which of the following actions should the nurse take next?
Warm the newborn's heel.
24 week gestation regarding a 1 hr glucose tolerance test
a blood glucose of 130 - 140 is considered a positive screen result
discharge teaching: circumcision
apply slight pressure with a sterile gauze pad for mild bleeding
12 hr postpartum pt wants to use the bathroom
assist the client to the bathroom to void
client 8cm dilated, 100% effaced, -2 station, fetus in occiput posterior position
assist the client to the hands and knees position
40 wk gestation, early labor, platelet 75000/mm requesting pain relief
attention-focusing
LD unit, client states "my water just broke", nursing priorty
begin FHR monitoring
non pharmacological pain management: breastfeeding and engorged
cold cabbage leaves
educational program for adolescents about nutrition third trimester
consume three to four servings of dairy each day
active labor, early deceleration in FHR, 39 wk gestation
continue monitoring the client
difference between true and false labor
contractions become stronger with walking
vag exam client in labor,fetal head posterior position, non pharmacological intervention
counter-pressure
newborn undergoing phototherapy to treat hyperbilirubinemia
cover the newborn's eyes while under the phototherapy light
postpartum and has idiopathic thrombocytopenia purpura
decreased platelet count
26 week gestation, manifestations should report
decreased urine output
22 wk gestation, blotchy hyperpigmentation
explain to the client this is an expected occurence
PICTURE: spina bifida occulta
first pic: bruise above buttocks
carboprost adverse effect for postpartum hemorrhage
hypertension
group of parents, newborn safety, indicates understanding
i will dress my baby in flame-retardant clothing
teaching: hyperemisis gravidarum
i will eat foods that appeal to my taste instead of trying to balance my meals
assessing fetal heart tones: where to assess the point of maximum intensity of the fetal heart
left lower quadrant
uterine hypotonicity experiencing postpartum hemorrhage
massage the clients fundus
developing plan of care preeclampsia and receiving mag sulfate IV
monitor FHR continously
requesting epidural anesthesia for pain
monitor the clients BP every 5 minutes following the first dose of anesthetic solution
prenatal class: taking folic acid during pregnancy
neural tube defect
newborn delivered vaginally, tight nuchal cord
petechiae over the head
blood specimen via heel stick
place the newborn skin to skin on mother's chest
teaching about using car seat properly
position the car seat rear-facing in the back seat of the vehicle
medical record, client first trimester, identify risk factor for preeclampsia
pregestational diabetes mellitus
24 week gestation reports daily mild headaches. Care plan
recommend that the client perform conscious relaxtion techniques daily
full-term newborn 15 min after birth, intervention by nurse
respiration 18/min (during the first phase of the newborn's transition into extrauterine life clinical manifestations that are normal include--HR 160-180/min, RR 20-100/min, tremors, crying, startling motions, fine crackles, and nasal flaring)
late preterm newborn, indication of hypoglycemia
respiratory distress
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
26 weeks, how to increase circulation to placenta
side-lying
how to use bulb syringe to suction newborn secretions
stop suction when the newborn's cry sounds clear
12 hr old, manifestations require intervention
substernal check retractions while sleeping
charge nurse on postpartum unit, new nurse administer pain med - charge nurse should intervene when the newly licensed nurse used which as a secondary identifier?
the clients room number
labor increasing rectal pressure
transition phase
discharge teaching postpartum, clinical manifestation should monitor and report
unilateral breast pain
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.
1 day postpartum has vaginal hematoma
vaginal pressure
newborn transferred to nursery 30 min after delivery
verify the newborn's identification
38 wk gestation, findings nurse should report
weight gain of 2.2 kg
cesarean birth 3 days ago
you can still become pregnant if you are breastfeeding
effective breastfeeding, client 3 day postpartum
your newborn should appear content after each feeding
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 discharge teaching about home care with the parent of a newborn. Which of the following instructions should the nurse include?
"Ensure the water temperature during your newborn's bath is maintained at 100 F."
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 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 reinforcing teaching about brestfeeding with a client who has a 12-hr-old newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I should wake up my baby to feed during the night."
teaching physiological changes, 10 wk gestation with BMI in range
"I will likely need to use alternative positions for sexual intercourse"
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."
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 teaching with a client who has an intrauterine device (IUD). Which of the following statements by the client indicates an understanding of the teaching
"If I have pain during intercourse, I will notify my doctor."
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 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 teaching with a client who has a bacterial infection. Which of the following statements should the nurse include int he teaching?
"You should suspend breastfeeding for 8-10 days."
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 is reinforcing teaching about newborn home safety precautions with a group of new mothers. Which of the following instructions should the nurse include?
"crib slats should be no more than 2.25 inches apart"
A nurse is reinforcing teaching with a client who is at 16 weeks of gestation, has diabetes mellitus, and has a BMI of 31. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"my intake should be 25 calories per kilogram of my body weight or less per day"
a nurse is planning to reinforce discharge teaching about formula feeding with the guardian of a newborn. Which of the following instructions should the nurse plan to include?
"provide the newborn with six to eight feedings during a 24-hr period"
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"
Client making decision about uterine tube occlusion, which response:
"this process should have no effect on your sexual performance or adequacy."
adolescent, levonorgesteral contraception
"you should take the medication within 72 hr following unprotected sexual intercourse''
36 wk gestation, nonstress test
"you will be offered orange juice to drink during the test"
client experienced perinatal death
''I am sad for you"
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 caring for a client who is 48 hr postpartum following a vaginal delivery. Which of the following findings should the nurse report to the provider? (SATA)
-Reddened area on the calf -Dysuria -Cracked nipples
family planning clinic, contraindication to oral contraceptives
-cholecystitis -hypertension -migraine headaches
physical assessment newborn , clinical manifestations should expect
-creases over two-thirds of the soles of the feet -Lanugo on shoulders -molding of the head
receive Oxytocin to augment labor, contraindications to report
-late decelerations
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
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 assisting with the care of a client who is postpartum and is receiving lactated Ringer's 1,500 mL IV to infuse over 10 hr. The nurse should verify that the IV pump's settings will deliver how many mL/hr?
150 mL/hr
assessing newborns, findings nurse should report
18 hour old with axillary temp of 37.7c
administer mag sulfate 2g/hr IV. Avail 20 g in 50 ml d5w, how many ml/hr
50
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 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 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 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 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
2 hr postpartum, intervention
Demonstrate to the client how to perform a newborn bath
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 hurting her." Which of the following actions should the nurse take first to promote parent-newborn attachment?
Demonstrate to the parent how to hold the newborn.
A nurse is monitoring a client who is in the first stage of labor and received IV fentanyl citrate 10 min ago for pain. The client has slurred speech and an altered mental status. Which of the following actions should the nurse take first?
Determine the client's oxygen saturation level.
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 contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend in the plan?
Drink 2 L of water per day.
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 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 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 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 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 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.
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 in an antepartum clinic is reviewing laboratory test results for multiple clients. The nurse should notify the provider of which of the following results?
Hematocrit 31%
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
pregestational type 1 diabetes
I will continue taking my insulin if I experience nausea and vomiting"
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 preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes?
Intramuscular
teaching nutritional intake client 8 week gestation
Iron
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
15 weeks gestation, Rh neg, had amniocentesis
Monitor the FHR
A nurse is caring for a client who is receiving oxytocin. Which of the following manifestations should the nurse report to the provider?
More than 5 contractions in 10 min.
7 year old accepting new baby
Obtain a gift from the newborn to present to the sibling
A nurse is reinforcing teaching about formula preparation with the mother of a newborn. Which of the following information should the nurse include?
Overdiluted formula can result in inadequate growth.
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 reviewing the medical record of a client who is at 26 weeks of gestation. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
Rheumatoid arthritis
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.
