VATI Maternal Newborn Assessment

VATI Maternal Newborn Assessment Related

Review VATI Maternal Newborn Assessment related questions and content

During a nursing assessment the woman with rupture

  • A. What is the nurse's priority action?
  • B. Use gravity and manipulation to relieve compression of the cord (butt up in the air and face down until ready to delivery)
  • C. Help the fetal head descend faster
  • D. Facilitate dilation of the cervix with prostaglandin gel
Correct Answer: A

Rationale: In the scenario presented, the nurse's priority action should be to call for emergent medical assistance. A woman with a rupture during a nursing assessment could be experiencing a serious complication known as umbilical cord prolapse. This occurs when the umbilical cord slips through the cervix ahead of the baby, which can lead to compression of the cord and a serious decrease in oxygen supply to the baby. It is a medical emergency that requires immediate intervention by the healthcare team, which may include moving the mother into a knee-chest position or performing a cesarean section. Therefore, the priority action for the nurse is to ensure prompt medical intervention to protect the well-being of both the mother and the baby.

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The nurse is planning to admit a pregnant client who is obese. Which potential client needs should the nurse anticipate?

  • A. Routine administration of subcutaneous heparin may be prescribed.
  • B. Bed rest as a necessary preventive measure may be prescribed.
  • C. An overbed lift may be necessary if the client requires a cesarean section.
  • D. Thromboembolism stockings or sequential compression devices may be prescribed.
Correct Answer: D

Rationale: Obese clients may need thromboembolism prevention and specialized equipment for safe cesarean handling.

Positive signs of pregnancy

  • A. FHR detected by electronic doppler @10-12 wks
  • B. Active fetal movements palpable by examiner
  • C. Outline of fetus by radiography or ultrasound
Correct Answer: B

Rationale: One of the positive signs of pregnancy is the active fetal movements palpable by the examiner. This occurs when the examiner is able to feel the movements of the fetus inside the uterus. This sign usually becomes noticeable in the second half of pregnancy and is a clear indication that the pregnancy is progressing normally. It is a reassuring sign for both the pregnant individual and the healthcare provider that the fetus is active and healthy.

The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?

  • A. Painless vaginal bleeding.
  • B. Hard, rigid abdomen with severe pain.
  • C. Clear amniotic fluid.
  • D. Regular uterine contractions.
Correct Answer: B

Rationale: A hard, rigid abdomen and severe pain are classic signs of placental abruption, requiring urgent intervention.

A client reports experiencing painless contractions at 32 weeks' gestation. What should the nurse explain?

  • A. These are Braxton Hicks contractions and are normal.
  • B. This is a sign of preterm labor.
  • C. This indicates cervical dilation.
  • D. This requires immediate hospitalization.
Correct Answer: A

Rationale: Braxton Hicks contractions are common in the third trimester and typically do not signify labor.

Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high- pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:

  • A. Hypovolemia
  • B. Hypocalcemia
  • C. Hypoglycemia
  • D. Hyperglycemia
Correct Answer: C

Rationale: The signs described in the scenario - jitteriness, weak high-pitched cry, irregular respirations - are indicative of hypoglycemia in a newborn. Babies born to mothers with diabetes are at risk for hypoglycemia due to their exposure to high blood sugar levels in utero. After birth, when the baby is separated from the mother's blood supply, their own insulin production may lead to a sudden drop in blood glucose levels.

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