ATI Maternal Newborn

ATI Maternal Newborn Related

Review ATI Maternal Newborn related questions and content

The nurse is educating a prenatal client about weight dysphoric disorder. Which statement by the client gain during pregnancy. Which statement by the would require immediate follow-up? client indicates effective understanding?

  • A. I have been crying the week of my period.
  • B. I should gain 2 to 4 pounds in the first trimester
  • C. I am experiencing suicidal thoughts. and half a pound per week in the last two
  • D. My menstrual cycle is 1 week late. trimesters.
Correct Answer: C

Rationale: Correct Answer: C. "I am experiencing suicidal thoughts."

Rationale: This statement indicates a serious mental health concern that requires immediate follow-up. Suicidal thoughts during pregnancy can be a sign of depression or other mental health issues that need to be addressed promptly to ensure the safety and well-being of the client and the baby.

Summary of Other Choices:
A: "I have been crying the week of my period." - This statement suggests premenstrual symptoms which are common and not necessarily alarming during pregnancy.
B: "I should gain 2 to 4 pounds in the first trimester and half a pound per week in the last two trimesters." - This statement reflects a correct understanding of weight gain recommendations during pregnancy and does not raise immediate concerns.
D: "My menstrual cycle is 1 week late." - This statement is not concerning during pregnancy as menstrual cycles typically stop during pregnancy.

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The nurse is performing a nonstress test. What result indicates a reactive test?

  • A. No fetal movements noted.
  • B. Two accelerations in 20 minutes.
  • C. Baseline fetal heart rate of 170 beats/minute.
  • D. Variable decelerations.
Correct Answer: B

Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.

A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:

  • A. Activates the liver to dispose the bilirubin
  • B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
  • C. Activates Vit. K to facilitate excretion of the bilirubin
  • D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B

Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

  • A. Massage the fundus.
  • B. Insert a urinary catheter.
  • C. Have the client urinate.
  • D. Administer an analgesic.
Correct Answer: C

Rationale: Correct Answer: C - Have the client urinate.

Rationale:
1. Displacement to the right of midline indicates a full bladder pushing the fundus.
2. A full bladder can prevent the fundus from contracting properly.
3. Having the client urinate will help the bladder empty, allowing the fundus to contract effectively and prevent complications like postpartum hemorrhage.

Summary of Incorrect Choices:
A: Massaging the fundus is not necessary as it is already firm.
B: Inserting a urinary catheter is invasive and should be avoided unless necessary.
D: Administering an analgesic is not indicated for fundus displacement; addressing the full bladder is the priority.

What question during a family assessment could the nurse ask to determine if the family has necessary resources?

  • A. Do you enjoy spending time with your family?
  • B. Do you have a group of friends, neighbors, or a church that helps you when you are ill?
  • C. How often do you go to the store by yourself?
  • D. Do your family members get along well?
Correct Answer: B

Rationale: The correct answer is B: "Do you have a group of friends, neighbors, or a church that helps you when you are ill?" This question assesses the family's support network and resources in times of need. It helps determine if the family has a social support system that can provide assistance during challenging situations. Options A, C, and D are incorrect as they do not directly address the availability of external resources for the family's well-being. Option A focuses on emotional aspects, C on independence, and D on family dynamics, which are not directly related to assessing resources.

As the infant nursery nurse, you are assisting with a

  • A. Assess the fetal station delivery. After the initial assessment of the baby,
  • B. Assess for rupture of the fetal membranes what is the next best action?
  • C. Determine dilation of the cervix
  • D. Give the infant a bath
Correct Answer: C

Rationale: Rationale for Correct Answer (C - Determine dilation of the cervix):
1. It is crucial to monitor the progress of labor by assessing cervical dilation.
2. Cervical dilation indicates the stage of labor and helps determine when the mother is ready to push.
3. This information guides the healthcare team in providing appropriate care and support during delivery.
4. Assessing fetal station or rupture of membranes is important but determining cervical dilation is the priority.

Summary:
- Option A is incorrect because assessing fetal station is not the immediate next step.
- Option B is incorrect as assessing for rupture of membranes is important but not the next immediate action.
- Option D is incorrect as giving the infant a bath is not a priority in the labor and delivery process.

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