ATI RN Maternal Newborn Online Practice 2024 A, RN Maternal Newborn 2024 online Practice 24 B - ATI

ATI RN Maternal Newborn Online Practice 2024 A, RN Maternal Newborn 2024 online Practice 24 B - ATI A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? 1-Hr Glucose Tolerance Test - 120 mg/dL Hematocrit - 34% Fundal Height Measurement - 30 cm Fetal Heart Rate - 110 bpm - ANSWER Fundal Height A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. 1-Hr GTT of 130-140 or greater indicates a need to report to provider. Hematocrit above 33% is normal FHR is normal (110-160/min) A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed - ANSWER RR 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Flushing and nausea are expected, but oliguria (levels of 25-30 mL/hr or less) is a sign of toxicity. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum - ANSWER Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Everything else is expected A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurses priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring. - ANSWER Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse (this is a common test question--Remember, cord compression is associated with variable decelerations and can happen after ROM). The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. Other actions are correct, but not priority. A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (select all that apply) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible - ANSWER Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. INCORRECT: Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record. - ANSWER Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band. A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia