Ati maternal newborn assessment
Ati maternal newborn assessment
Total Questions : 39
Showing 10 questions Sign up for moreA nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?
Explanation
A. WBC count 35,000/mm³: Incorrect. While a slightly elevated WBC count can be observed in response to stress or minor trauma, such as a cephalohematoma, the value provided (35,000/mm³) is elevated but not specific to cephalohematoma.
B. Glucose 35 mg/dL: Incorrect. Hypoglycemia (glucose <40 mg/dL) is not directly related to cephalohematoma. The condition primarily affects bilirubin levels, not glucose.
C. Bilirubin 14.0 mg/dL: Correct. Cephalohematoma can lead to increased bilirubin levels as the accumulated blood breaks down, causing jaundice. This finding is consistent with the expected increase in bilirubin due to the condition.
D. Platelet count 350,000/mm³: Incorrect. A normal platelet count does not directly correlate with cephalohematoma. The platelet count given is within the normal range and is not indicative of the condition.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?
Explanation
A. BUN 30 mg/dL: Correct. Elevated BUN (blood urea nitrogen) levels are associated with impaired kidney function, which is common in preeclampsia.
B. Hgb 9.9 g/dL: Incorrect. While anemia can occur in preeclampsia, it is not the primary laboratory finding associated with the condition. The hemoglobin level provided is low but not specific to preeclampsia.
C. Serum uric acid 2.5 mg/dL: Incorrect. Elevated serum uric acid levels are often associated with preeclampsia, but the value provided is below the normal range and would not be expected in this condition.
D. Casual blood glucose 228 mg/dL: Incorrect. Although gestational diabetes can occur, it is not a direct result of preeclampsia. The glucose level given is high but not specific to the condition.
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
Explanation
A. Hyporeactivity: Incorrect. Neonatal abstinence syndrome (NAS) typically presents with hyperreactivity rather than hyporeactivity. Newborns with NAS are usually more irritable and agitated.
B. Excessive high-pitched cry: Correct. A high-pitched cry is a common manifestation of NAS, indicating central nervous system irritability. This symptom, along with others, is consistent with withdrawal from opioids such as methadone.
C. Acrocyanosis: Incorrect. Acrocyanosis, which refers to the bluish discoloration of the hands and feet, is common in newborns but is not specific to NAS. It is typically a transient and benign condition.
D. Respiratory rate of 50/min: Incorrect. A respiratory rate of 50/min is within the normal range for a newborn and is not indicative of NAS. NAS is more commonly associated with symptoms such as irritability and abnormal crying.
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
Explanation
A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.
B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.
C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.
D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?
Explanation
A. Discourage the client from looking at their breasts: Incorrect. Discouraging the client from looking at their breasts may prevent them from processing their feelings and adjusting to their new body image. It is important to support the client in exploring and accepting their changed body.
B. Recommend a support group for the client to attend: Correct. A support group can provide the client with emotional support and practical advice from others who have experienced similar challenges. This can help the client cope with changes in body image and emotional responses.
C. Tell the client you are so sorry for how devastated they must feel: Incorrect. While showing empathy is important, this response does not actively address the client's concerns or provide practical support. It is more beneficial to offer concrete resources and coping strategies.
D. Tell the client to focus on their postoperative recovery for now: Incorrect. Although focusing on recovery is important, it is also crucial to address the client's emotional concerns about body image. Ignoring these concerns may affect their overall emotional well-being.
A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)
Explanation
A. Instruct the client to wash their hands prior to breastfeeding: Correct. Proper hand hygiene helps to prevent the spread of infection, which is important for a client with mastitis. Washing hands before breastfeeding is a crucial infection control measure.
B. Teach the client about proper latching-on techniques: Correct. Proper latching-on techniques can help prevent further complications and ensure effective milk removal, which can help in managing mastitis and preventing recurrence.
C. Encourage the client to alternate breastfeeding with formula feeding: Incorrect. Breastfeeding should continue as usual because it helps to empty the breast and relieve engorgement, which is crucial for managing mastitis. Formula feeding could exacerbate the problem by increasing engorgement.
D. Instruct the client to avoid using a breast pump: Incorrect. Using a breast pump can be beneficial for managing mastitis by helping to relieve engorgement and ensure proper milk drainage. The pump should be used correctly and hygienically.
E. Encourage the client to allow their nipples to air dry after feedings: Correct. Allowing the nipples to air dry helps prevent further irritation and infection. It is important for maintaining skin integrity and comfort during mastitis.
A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply)
Explanation
A. Nulliparity: Correct. Nulliparity, or never having been pregnant, is a known risk factor for ovarian cancer. Women who have never given birth have a higher risk of developing ovarian cancer compared to those who have had one or more children.
B. History of breastfeeding: Incorrect. Breastfeeding is generally associated with a decreased risk of ovarian cancer. It is thought to reduce the number of lifetime ovulatory cycles, thereby potentially lowering the risk.
C. Previous use of oral contraceptives: Incorrect. The use of oral contraceptives is associated with a reduced risk of ovarian cancer. Long-term use can significantly decrease the risk, and the protective effect may continue for years after discontinuation.
D. History of breast cancer: Correct. A history of breast cancer is a risk factor for ovarian cancer, particularly in women with BRCA1 or BRCA2 gene mutations. These mutations increase the risk of both breast and ovarian cancers.
E.Use of postmenopausal estrogen: Correct. The use of postmenopausal estrogen, especially when used without progesterone, is associated with an increased risk of ovarian cancer. Estrogen therapy can stimulate the growth of ovarian tumors in susceptible women.
A nurse providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include in the teaching?
Explanation
A. Peanut butter sandwich: Incorrect. Peanut butter contains phenylalanine, an amino acid that people with phenylketonuria (PKU) must limit in their diet. Foods high in phenylalanine should be avoided to prevent complications.
B. Sliced apples: Correct. Sliced apples are low in phenylalanine and safe for individuals with PKU. Fruits are generally recommended for PKU patients as they provide essential nutrients without significant amounts of phenylalanine.
C. Glass of skim milk: Incorrect. Milk, including skim milk, contains phenylalanine, which should be limited or avoided by individuals with PKU. They need to consume specially formulated low-phenylalanine products.
D. Scrambled egg: Incorrect. Eggs are high in phenylalanine and should be avoided by individuals with PKU. They need to choose low-protein alternatives that do not contribute to their phenylalanine levels.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
Explanation
A. Prepare the necessary equipment to initiate an amnioinfusion: Incorrect. While amnioinfusion may be considered for recurrent variable decelerations caused by umbilical cord compression, the priority is to address the immediate cause of the decelerations, which may be due to excessive oxytocin.
B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord: Incorrect. Although checking for umbilical cord prolapse is important, the first action should be to address any potential causative factors like oxytocin use before performing an examination.
C. Discontinue the infusion of oxytocin: Correct. Recurrent variable decelerations can be a sign of umbilical cord compression, often exacerbated by excessive uterine contractions induced by oxytocin. Discontinuing the infusion is a critical first step to alleviate the pressure on the umbilical cord and improve fetal heart rate patterns.
D. Provide instructions for the client about potential preparation for birth: Incorrect. Providing instructions about preparation for birth is important but does not address the immediate issue of recurrent variable decelerations and their potential cause.
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. "If my partner is Rh-negative, I will not receive the shot.": Incorrect. Rho(D) immune globulin is administered based on the Rh status of the baby, not the partner. The client will receive the shot if the baby is Rh-positive or if the Rh status is unknown.
B. "I will receive the shot after delivery if my baby is Rh-negative.": Incorrect. Rho(D) immune globulin is given after delivery if the baby is Rh-positive. If the baby is Rh-negative, the shot is not necessary.
C. "I should not receive any immunizations for 3 months after the shot.": Incorrect. There are no restrictions on receiving other immunizations after receiving Rho(D) immune globulin, and there is no need to wait for 3 months.
D. "This shot may be given after birth to protect future pregnancies.": Correct. Rho(D) immune globulin is given postpartum if the baby is Rh-positive to prevent the development of antibodies that could affect future pregnancies.
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