Review ATI Maternal Newborn Exam 4

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ATI Maternal Newborn Exam 4

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Total Questions : 64

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Question 1:

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth, the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress?

A. Hypoglycemia B. Phrenic nerve injury C. Sepsis D. Meconium aspiration syndrome

Answer and Explanation

Choice A:

Hypoglycemia is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers. However, hypoglycemia does not explain the high FHR, the low Apgar scores, or the pale and tachypneic appearance of the newborn.

Choice B:

Phrenic nerve injury is a rare complication of cesarean section that can cause diaphragmatic paralysis and respiratory distress in the newborn. However, phrenic nerve injury usually affects only one side of the chest, and does not cause high FHR, low Apgar scores, or pallor.

Choice C:

Sepsis is a serious infection that can affect newborns, especially those who are exposed to prolonged rupture of membranes, as in this case. Sepsis can cause high FHR, low Apgar scores, pale and tachypneic appearance, and other signs of shock and organ failure.

Choice D:

Meconium aspiration syndrome is a condition where the newborn inhales meconium-stained amniotic fluid into the lungs, causing respiratory distress. However, meconium aspiration syndrome usually occurs in term or post-term infants, and is associated with low FHR, not high FHR. Meconium aspiration syndrome also causes cyanosis, not pallor.

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Question 2:

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

A. Use fingertips when calming the newborn. B. Position the premature infant on their abdomen. C. Keep the newborn in a well-lit nursery. D. Cluster the newborn's care activities.

Answer and Explanation

Choice A:

Using fingertips when calming the newborn is not recommended, as it can overstimulate the immature nervous system and cause stress. Instead, the nurse should use gentle, firm, and sustained touch, such as cupping the head and feet, or swaddling the newborn.

Choice B:

Positioning the premature infant on their abdomen is contraindicated, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should position the newborn on their back or side, with a rolled blanket or towel to support the spine and prevent flattening of the head.

Choice C:

Keeping the newborn in a well-lit nursery is not advisable, as it can interfere with the development of the circadian rhythm and sleep patterns. The nurse should provide a dark and quiet environment for the newborn, and expose them to natural light during the day.

Choice D:

Clustering the newborn's care activities is beneficial, as it can reduce the number of disruptions and allow for longer periods of rest and growth. The nurse should plan and coordinate the care activities, such as feeding, bathing, changing, and assessing, to minimize the stress on the newborn.

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Question 3:

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

A. "Your baby needs this medication to fight a possible respiratory tract infection." B. "Surfactant is used to reduce episodes of periodic apnea." C. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." D. "The drug keeps your baby from requiring too much sedation."

Answer and Explanation

Choice A:

This statement is incorrect, as surfactant is not an antibiotic and does not treat infections. Surfactant is a substance that is naturally produced by the lungs to reduce the surface tension and prevent the alveoli from collapsing. Premature infants may have insufficient surfactant, which can cause RDS.

Choice B:

This statement is partially true, as surfactant can help reduce episodes of periodic apnea, which is a condition where the newborn stops breathing for more than 20 seconds. However, this is not the main purpose of surfactant therapy, and other interventions, such as oxygen, ventilation, and caffeine, may be needed to treat apnea.

Choice C:

This statement is correct, as surfactant improves the ability of the baby's lungs to exchange oxygen and carbon dioxide, which are essential for life. Surfactant therapy can improve the lung function, reduce the need for mechanical ventilation, and prevent complications, such as bronchopulmonary dysplasia and pulmonary hemorrhage.

Choice D:

This statement is false, as surfactant does not affect the level of sedation in the newborn. Surfactant is administered through an endotracheal tube, which may require sedation to reduce discomfort and agitation. The nurse should monitor the newborn's vital signs, oxygen saturation, and pain level during and after the procedure.

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Question 4:

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

A. Contractions occurring every 3 to 5 min B. Each contraction lasting longer than 110 seconds C. Contractions are strong in intensity D. Client reports feeling contractions in lower back

Answer and Explanation

Choice A:

Contractions occurring every 3 to 5 min are normal and expected in the active phase of the first stage of labor, which lasts from 4 to 8 cm of cervical dilation. The nurse does not need to report this finding to the provider.

Choice B:

Each contraction lasting longer than 110 seconds is abnormal and concerning, as it can indicate uterine hyperstimulation, which can reduce the blood flow to the placenta and fetus, and cause fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions, such as stopping oxytocin infusion, administering tocolytics, or performing an emergency cesarean section.

Choice C:

Contractions are strong in intensity are also normal and expected in the active phase of the first stage of labor, as they facilitate the cervical dilation and effacement. The nurse does not need to report this finding to the provider.

Choice D:

Client reports feeling contractions in lower back are common and not harmful, especially if the fetus is in the occiput posterior position, which causes the fetal head to press against the sacrum. The nurse does not need to report this finding to the provider, but can offer comfort measures, such as massage, counterpressure, heat, or position changes.

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Question 5:

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

A. Polyuria B. Report of headache C. Tachycardia D. Absence of clonus

Answer and Explanation

Choice A:

Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.

Choice B:

Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.

Choice C:

Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.

Choice D:

Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.

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Question 6:

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A. Irregular fetal heart rate B. Rapid decline in human chorionic gonadotropin (hCG) levels C. Profuse, clear vaginal discharge D. Excessive uterine enlargement

Answer and Explanation

Choice A:

Irregular fetal heart rate is not an expected finding in a client with a hydatidiform mole, as it can indicate fetal arrhythmia, distress, or demise. A client with a hydatidiform mole may have no fetal heart tones, as the pregnancy is nonviable and consists of abnormal trophoblastic tissue.

Choice B:

Rapid decline in human chorionic gonadotropin (hCG) levels is not an expected finding in a client with a hydatidiform mole, as it can indicate a normal or abnormal termination of pregnancy. A client with a hydatidiform mole may have markedly elevated hCG levels, as the trophoblastic tissue secretes excessive amounts of the hormone.

Choice C:

Profuse, clear vaginal discharge is not an expected finding in a client with a hydatidiform mole, as it can indicate a normal or abnormal cervical mucus production. A client with a hydatidiform mole may have vaginal bleeding, which is often dark brown or bright red, and may contain grape-like vesicles.

Choice D:

Excessive uterine enlargement is an expected finding in a client with a hydatidiform mole, as it reflects the rapid growth of the trophoblastic tissue and the accumulation of fluid-filled vesicles. A client with a hydatidiform mole may have a uterus that is larger than expected for the gestational age, and may experience uterine cramping or pain.

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Question 7:

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

A. Nervousness B. Tremors C. Dyspnea D. Headaches

Answer and Explanation

Choice A:

Nervousness is a common and expected side effect of terbutaline, which is a beta-2 adrenergic agonist that stimulates the sympathetic nervous system and relaxes the uterine smooth muscle. The nurse does not need to report this finding to the provider, but can provide reassurance and comfort to the client.

Choice B:

Tremors are also a common and expected side effect of terbutaline, as it causes increased muscle activity and shakiness. The nurse does not need to report this finding to the provider, but can monitor the client's vital signs and electrolyte levels, and advise the client to avoid caffeine and other stimulants.

Choice C:

Dyspnea is an uncommon and serious side effect of terbutaline, as it can indicate pulmonary edema, which is a life-threatening condition where fluid accumulates in the lungs and impairs gas exchange. The nurse should report this finding to the provider immediately and prepare for interventions, such as oxygen therapy, diuretics, or discontinuation of terbutaline.

Choice D:

Headaches are also a common and expected side effect of terbutaline, as it causes vasodilation and increased blood flow to the brain. The nurse does not need to report this finding to the provider, but can administer analgesics as prescribed, and encourage the client to rest and hydrate.

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Question 8:

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new order for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

A. "It promotes fetal lung maturity." B. "It halts cervical dilation." C. "It increases the fetal heart rate." D. "It is used to stop preterm labor contractions."

Answer and Explanation

Choice A:

This statement is correct, as betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering before 34 weeks of gestation. Betamethasone stimulates the production of surfactant, which is a substance that prevents the alveoli from collapsing and improves the lung function of the fetus.

Choice B:

This statement is incorrect, as betamethasone does not affect the cervical dilation, which is a sign of labor progression. Betamethasone does not stop or delay labor, but rather reduces the complications of prematurity, such as respiratory distress syndrome, intraventricular hemorrhage, or necrotizing enterocolitis.

Choice C:

This statement is incorrect, as betamethasone does not increase the fetal heart rate, which is a measure of fetal well-being. Betamethasone may cause transient fetal bradycardia, which is a decrease in the fetal heart rate, due to the increased vagal tone and blood pressure. The nurse should monitor the fetal heart rate and notify the provider if there are any signs of fetal distress.

Choice D:

This statement is incorrect, as betamethasone is not used to stop preterm labor contractions, which are caused by the uterine muscle activity. Betamethasone does not have any tocolytic effect, which is the ability to inhibit uterine contractions. Other medications, such as magnesium sulfate, nifedipine, or indomethacin, may be used to stop preterm labor contractions.

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Question 9:

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

A. "At least you know you have a healthy baby." B. "You can resume sexual relations sooner than if you had delivered vaginally." C. "Maybe next time you can have a vaginal delivery." D. "It sounds like you are feeling sad that things didn't go as planned."

Answer and Explanation

Choice A:

This statement is insensitive and dismissive, as it implies that the client's feelings are not valid or important. The nurse should not minimize the client's disappointment or guilt, but rather acknowledge and respect them.

Choice B:

This statement is inaccurate and irrelevant, as it does not address the client's emotional needs or concerns. The nurse should not give false or misleading information, or focus on the physical aspects of recovery, but rather provide emotional support and education.

Choice C:

This statement is presumptuous and unrealistic, as it assumes that the client wants or can have another pregnancy, and that a vaginal delivery is possible or preferable. The nurse should not make assumptions or promises, or compare different modes of delivery, but rather explore the client's feelings and expectations.

Choice D:

This statement is empathetic and respectful, as it reflects the client's feelings and validates them. The nurse should use active listening and therapeutic communication skills, such as open-ended questions, clarifications, and summarizations, to help the client cope and express her emotions.

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Question 10:

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 11 lb 6 oz. (5160 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

A. Thrombophlebitis B. Retained placental fragments C. Puerperal infection D. Uterine atony

Answer and Explanation

Choice A:

Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation and pain. The risk factors for thrombophlebitis include immobility, dehydration, obesity, smoking, and cesarean birth. This client is not at increased risk for thrombophlebitis based on the information given.

Choice B:

Retained placental fragments are pieces of the placenta that remain in the uterus after delivery and can cause bleeding, infection, or uterine subinvolution. The risk factors for retained placental fragments include placenta previa, placenta accreta, manual removal of the placenta, and incomplete separation of the placenta. This client is not at increased risk for retained placental fragments based on the information given.

Choice C:

Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery and can cause fever, malaise, abdominal pain, and foul-smelling lochia. The risk factors for puerperal infection include prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, operative delivery, and retained placental fragments. This client is not at increased risk for puerperal infection based on the information given.

Choice D:

Uterine atony is a condition where the uterus fails to contract and retract after delivery and can cause excessive bleeding, hypovolemic shock, and hemorrhage. The risk factors for uterine atony include overdistension of the uterus, prolonged labor, oxytocin use, anesthesia, and trauma. This client is at increased risk for uterine atony due to the large size of the newborn, which can overstretch the uterus and impair its ability to contract.

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Total Questions : 64

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ATI Maternal Newborn Exam 4

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