ATI RN MATERNAL NEWBORN A EXAM WITH EXPLANATIONS 

ATI RN MATERNAL NEWBORN A EXAM WITH EXPLANATIONS  A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid  replacement. Which of the following findings should the nurse report to the provider? correct-a. BUN 25 mg/dL rationale  The nurse should report an elevated BUN to the provider since it can indicate  dehydration. A nurse is assessing four newborns. Which of the following findings should the nurse  report to the provider? correct -d. a newborn who is 18 hr old and has an axillary temperature of 37.7 degrees  Celsius rationale  An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference  range for a newborn and can be an indication of sepsis. Therefore, the nurse should  report this finding to the provider. A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the  following findings should the nurse report to the provider? Select the 3 findings that  should be reported? - correct -Uterine contractions is correct.  rationale  The client is experiencing regular uterine contractions and cervical change, which are  indicators of preterm labor; therefore, the nurse should notify the provider about this  finding. Fetal heart rate is incorrect. The fetal heart rate is within the expected reference  range; therefore, the nurse should not report this finding to the provider. Gestational age is correct. The client is at 32 weeks of gestation and is experiencing  regular uterine contractions and cervical dilation, which indicates that the client is in  preterm labor; therefore, the nurse should notify the provider about this finding. Vaginal examination is correct. The client's cervix is dilated to 2 cm and is 50% effaced,  which indicate the client is in preterm labor; therefore, the nurse should notify the  provider about this finding. Maternal blood pressure is incorrect. The client's blood pressure is within the expected  reference range; therefore, the nurse should not report this finding to the provider. For each assessment finding, click to specify if the finding is consistent with  hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one  disease process. - correct -Decreased temperature is associated with hypoglycemia  and sepsis. rationale  Yellow sclera and oral mucosa are associated with hyperbilirubinemia and sepsis. Poor  feeding is associated with hypoglycemia, hyperbilirubinemia and sepsis. Ecchymosis  caput succedaneum is associated hyperbilirubinemia. Respiratory distress is associated  with hypoglycemia and sepsis. Lethargy is associated with hypoglycemia and sepsis. A nurse is teaching a client who has pregestational type 1 diabetes mellitus about  management during pregnancy. Which of the following statements by the client  indicates an understanding of the teaching? - correct -c. "I will continue taking my insulin if I experience nausea and vomiting."     rationale  The nurse should teach the client to continue to take their insulin as prescribed during  illness to prevent hypoglycemic and hyperglycemic episodes. A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which  of the following findings should the nurse report to the provider as a potential  complication? - correct -b. leakage of fluid from the vagina rationale  Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and  should be reported to the provider. Exhibit 1: Medical hx Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight  3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of  methadone use during pregnancy. Exhibit 2: VS @0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F)  Oxygen saturation 98% on room air @1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F)  Oxygen saturation 96% on room air Exhibit 3: Phys Exam Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier  but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation.  Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive  Moro reflex noted. Several loose stools today. Exhibit 4: Diagnostic Results Maternal urine toxicology screen positive for opiates (-). Newborn urine toxicology  screen positive for opiates (- - ANSWER-Respiratory findings is incorrect. The newborn's  respiratory rate is within the expected reference range of 30 to 60/min. There is no  indication the newborn has an alteration in respiratory status; therefore, this finding  does not need to be reported to the provider. Temperature is incorrect. The newborn's temperature is within the expected reference  range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be  reported to the provider. Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected  reference range of greater than 94%; therefore, this finding does not need to be  reported to the provider. Central nervous system findings is correct. The newborn is displaying inconsolability,  high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported to  the provider. Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose  stools. These findings are manifestations of NAS and should be reported to the provider. Exhibit 1: RN note @ 0900: Client reports a small amount of bright red blood in their underwear upon  awakening. Client denies contractions or abdominal pain. External fetal monitor  applied. @0930: Client passed large amount of bright red blood from vagina. Denies pain. Uterine  tone soft and nontender to palpation. Contraction pattern: no contractions noted. Fetal  heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No  decelerations noted. Exhibit 2: VS @0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood  pressure 112/64 mmHg. Fetal heart rate 132/min @0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min Exhibit 3: Medical hx G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section - ANSWER-When generating solutions, inserting a large bore intravenous catheter is  indicated. Clients who have third trimester vaginal bleeding may experience a sudden  hemorrhage and require fluid resuscitation or the administration of blood products. The  nurse should weigh perineal pads. Weighing perineal pads after use will provide a more  accurate assessment of the volume of blood loss that the client is experiencing.