ATI Maternal Newborn

ATI Maternal Newborn Related

Review ATI Maternal Newborn related questions and content

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

  • A. Notify the provider of the findings.
  • B. Position the client with one hip elevated.
  • C. Ask the client if she needs pain medication.
  • D. Have the client void.
Correct Answer: B

Rationale: The correct answer is B: Position the client with one hip elevated. This is the priority action because the client's contractions are frequent and of significant duration, indicating active labor. Elevating one hip can help improve fetal oxygenation and blood flow during contractions. It can also help optimize fetal positioning for a smoother labor process.

Choice A: Notifying the provider is important but not the priority at this moment. The nurse should first address immediate client needs.
Choice C: Asking about pain medication is important, but managing the client's positioning for labor progress takes precedence.
Choice D: Having the client void is a routine step in labor management but is not the priority action in this scenario.

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A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?

  • A. Your baby will have excess baby fat.
  • B. Your baby will have flat areola without breast buds.
  • C. Your baby's heels will easily move to his ears.
  • D. Your baby's skin will have a leathery appearance.
Correct Answer: D

Rationale: The correct answer is D because a baby who is postmature may have dry, cracked, and peeling skin, leading to a leathery appearance due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa diminishes over time. Choice A is incorrect because excess baby fat is not a typical characteristic of postmaturity. Choice B is incorrect as flat areola without breast buds is not a common feature of postmaturity. Choice C is incorrect as the ability to easily move heels to ears is a sign of flexibility and does not specifically relate to postmaturity.

A newborn is noted to have secretions bubbling out of the nose and mouth after delivery. What is the nurse's priority action?

  • A. Suction the nose with a bulb syringe.
  • B. Suction the mouth with a bulb syringe.
  • C. Use a suction catheter with low negative pressure.
  • D. Turn the newborn on their side.
Correct Answer: B

Rationale: The correct answer is B: Suction the mouth with a bulb syringe. This is the priority action because secretions in the mouth can obstruct the airway and lead to respiratory distress. Suctioning the mouth first helps clear the airway effectively. Suctioning the nose with a bulb syringe (choice A) may not address the immediate risk of airway obstruction. Using a suction catheter with low negative pressure (choice C) can be too strong for a newborn. Turning the newborn on their side (choice D) may not effectively address the airway obstruction from secretions in the mouth.

During the third trimester of pregnancy, which of the following findings should a nurse recognize as an expected physiologic change?

  • A. Gradual lordosis
  • B. Increased abdominal muscle tone
  • C. Posterior neck flexion
  • D. Decreased mobility of pelvic joints
Correct Answer: A

Rationale: The correct answer is A: Gradual lordosis. During the third trimester, the growing uterus shifts the center of gravity forward, leading to an increased lumbar curvature known as lordosis. This change helps maintain balance and support the extra weight. Increased abdominal muscle tone (B) is not an expected finding as abdominal muscles tend to stretch and weaken during pregnancy. Posterior neck flexion (C) is not a common physiologic change during the third trimester. Decreased mobility of pelvic joints (D) is incorrect as hormonal changes during pregnancy actually increase flexibility in the pelvic joints to prepare for childbirth.

A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?

  • A. I will keep the baby's head elevated while feeding.
  • B. I will allow the baby to burp several times during each feeding.
  • C. I will tilt the bottle to prevent air from entering as the baby sucks.
  • D. My baby will have soft, formed yellow stools.
Correct Answer: C

Rationale: The correct answer is C. Tilt the bottle to prevent air from entering as the baby sucks is incorrect. It is important not to tilt the bottle as it can cause the baby to swallow air, leading to gas and discomfort. A: Keeping the baby's head elevated helps prevent choking. B: Allowing the baby to burp reduces gas and discomfort. D: Soft, formed yellow stools indicate a healthy digestive system. Thus, C is the only statement that may lead to issues and requires further instruction.

A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

  • A. Apply cold compresses to the affected extremity
  • B. Massage the affected extremity
  • C. Allow the client to ambulate
  • D. Measure leg circumferences
Correct Answer: D

Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.

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