PN ATI Capstone Maternal Newborn

PN ATI Capstone Maternal Newborn Related

Review PN ATI Capstone Maternal Newborn related questions and content

A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

  • A. Administer oxygen
  • B. Change the client's position
  • C. Increase IV fluids
  • D. Call the healthcare provider
Correct Answer: B

Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps to improve placental blood flow, which can reduce the stress on the fetus. If the decelerations continue, further interventions, including oxygen administration and notifying the provider, may be necessary.

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A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

  • A. Assess the infant's bilirubin levels
  • B. Initiate phototherapy
  • C. Monitor the infant's temperature
  • D. Encourage breastfeeding
Correct Answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy.

A postpartum client's fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following interventions should the nurse take?

  • A. Massage the fundus
  • B. Administer oxytocin
  • C. Assist the client to void then reassess the fundus
  • D. Notify the healthcare provider
Correct Answer: C

Rationale: Displacement of the uterus from the midline is often a sign of bladder distention. A full bladder can prevent the uterus from contracting properly, which could increase the risk of postpartum hemorrhage. The nurse should assist the client to void and then reassess the position and firmness of the fundus to ensure appropriate uterine contraction.

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?

  • A. Digoxin
  • B. Calcium gluconate
  • C. Vitamin B6
  • D. Propranolol
Correct Answer: C

Rationale: Vitamin B6 (pyridoxine) is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum, and is considered safe for use in pregnant clients.

A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

  • A. Administer oxytocin to the client via intravenous infusion
  • B. Apply oxygen at 2 L/min via nasal cannula
  • C. Prepare for insertion of an intrauterine pressure catheter
  • D. Assist the client into the knee-chest position
Correct Answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation.

To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a:

  • A. Prone position
  • B. Supine position
  • C. Side-lying position
  • D. Semi-fowler's position
Correct Answer: B

Rationale: The safest sleeping position for infants is on their back (supine position). This reduces the risk of sudden infant death syndrome (SIDS), as sleeping in other positions can increase the risk of airway obstruction.

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