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Which patient is most at risk for a low-birth-weight infant?
- A. 22-year-old, 60 inches tall, normal prepregnant weight
- B. 18-year-old, 64 inches tall, body mass index is <18.5
- C. 30-year-old, 78 inches tall, prepregnant weight is 15 lb above the norm
- D. 35-year-old, 75 inches tall, total weight gain in previous pregnancies was 33 lb
Correct Answer: B
Rationale: The correct answer is B because a low body mass index (<18.5) indicates underweight, which is a risk factor for delivering a low-birth-weight infant. Underweight individuals may have inadequate nutrition and lower reserves for a healthy pregnancy.
Choice A is less likely as the patient has a normal prepregnant weight. Choice C's prepregnant weight being above the norm suggests a healthy weight. Choice D's total weight gain in previous pregnancies being 33 lb indicates a healthy weight maintenance during pregnancy.
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ATI Maternal Newborn
- A. Teach the patient about MyPlate.
- B. Review the patient's current dietary intake.
- C. Instruct the patient to limit the intake of fatty foods.
- D. Caution the patient to avoid large doses of vitamins, especially those that are fat-soluble.
Correct Answer: B
Rationale: The correct answer is B because reviewing the patient's current dietary intake provides crucial information on their nutrition status and helps identify any deficiencies or excesses. This step allows for personalized dietary recommendations tailored to the patient's specific needs.
A: Teaching about MyPlate is a general recommendation but does not address the individual patient's dietary requirements.
C: Instructing to limit fatty foods is a generic recommendation and may not be appropriate for every patient.
D: Cautioning against large doses of fat-soluble vitamins is important, but it is not the initial step in assessing the patient's overall dietary intake.
The home health nurse visits a client who delivered a full-term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curl-like patches on the newborns oral mucous membranes. What action should the nurse implement?
- A. Discuss the need for medication to treat curl-like oral patches
- B. Suggest switching the infant's formula
- C. Assess the baby's blood glucose level
- D. Remind mother not put the baby to bed with a propped bottle
Correct Answer: A
Rationale: White patches suggest thrush, which requires antifungal treatment (A).
The nurses assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indication that the infant is transitioning well to extrauterine life?
- A. Heart rate 220 beats/minute
- B. Cries vigorously when stimulated
- C. A positive Babinski reflex
- D. Flexion of all four extremities
Correct Answer: B
Rationale: Vigorous crying (B) indicates effective transition to extrauterine life.
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
- A. Uterus soft
- B. Contraction duration of 100 seconds
- C. Four contractions in 10 minutes
- D. Early deceleration of fetal heart rate
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds (B) can compromise fetal oxygenation and require discontinuing oxytocin.
A client at 40-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 8 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.