ATI Maternal Newborn B
Nurse is caring for a newborn who was transferred to nursery 30 min after birth bc of mild resp distress.
Which actions should the nurse take first?
Confirm the newborn's Apgar score.
Verify the newborn's identification.
Administer vitamin K to the newborn.
Determine obstetrical risk factors. - CORRECT Confirm the newborn's Apgar score:
- The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The
nurse should confirm the score when the newborn arrives in the nursery. However, there is another
action the nurse should take first.
ANS: Verify the newborn's identification:
- When using the safety/risk reduction approach to client care, the first action the nurse should take is to
verify the newborn's identity upon arrival to the nursery.
Administer vitamin K to the newborn:
- The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors
and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first
breastfeeding if necessary. Therefore, there is another action the nurse should take first.
Determine obstetrical risk factors:
- The nurse should identify obstetrical risk factors to determine if interventions are required for the
newborn. However, there is another action the nurse should take first.
Nurse is caring for patient who is in labor and reports increasing rectal pressure. Experiencing
contractions 2-3 min apart, each lasting 80-90 secs, and a vag exam reveals that her cervix is dilated 9
cm. Nurse should ID that patient is in which phases of labor?
,Active
Transition
Latent
Descent - CORRECT Active:
- The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3
to 5 min, each lasting 40 to 70 seconds.
ANS: Transition:
- The nurse should identify that the client is in the transition phase of labor. This phase is characterized
by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.
Latent:
- The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to
30 min, each lasting 30 to 45 seconds.
Descent:
- The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each
lasting for 90 seconds.
Nurse is teaching patient who is at 24 weeks gestation regarding a 1 hr glucose tolerance test. Which
statements should nurse include in teaching?
"You will need to drink the glucose solution 2 hours prior to the test."
"Limit your carbohydrate intake for 3 days prior to the test."
"A blood glucose of 130 to 140 is considered a positive screening result."
"You will need to fast for 12 hours prior to the test." - CORRECT "You will need to drink the glucose
solution 2 hours prior to the test.":
,- The nurse should instruct the client to drink the glucose solution 1 hr prior to the test.
"Limit your carbohydrate intake for 3 days prior to the test.":
- The nurse should instruct the client that she should not limit her carbohydrate intake.
ANS: "A blood glucose of 130 to 140 is considered a positive screening result.":
- The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a
positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose
tolerance test to confirm if she has gestational diabetes mellitus.
"You will need to fast for 12 hours prior to the test.":
- The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.
Nurse is assessing patient who gave birth vaginally 12 hrs ago and palpates her uterus to right above
umbilicus. Which interventions should the nurse perform?
Reassess the client in 2 hr.
Administer simethicone.
Assist the client to empty her bladder.
Instruct the client to lie on her right side. - CORRECT Reassess client in 2 hr:
- The nurse should assess the client more frequently after birth to determine the position of the uterus
and to intervene as soon as possible if necessary.
Administer simethicone:
- The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive
gas.
, ANS: Assist the client to empty her bladder:
- The nurse should assist the client to empty her bladder because the assessment findings indicate that
the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased
vaginal bleeding or postpartum hemorrhage.
Instruct the client to lie on her right side:
- Lying on her right side will not resolve the client's displaced uterus.
Nurse calculating a patient's expected DOB using nagele's rule. Client tells nurse that her last menstrual
cycle started on Nov 27th. Which dates is the patient expected DOB?
September 3rd
September 20th
August 3rd
August 20th - CORRECT ANS: September 3rd:
- When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract
3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th
minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.
September 20th:
- When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract
3 months from the first day of the client's last menstrual cycle and then add 7 days. Therefore, the
correct date is September 3rd.
August 3rd:
-"
August 20th:
Nurse is caring for a newborn who was transferred to nursery 30 min after birth bc of mild resp distress.
Which actions should the nurse take first?
Confirm the newborn's Apgar score.
Verify the newborn's identification.
Administer vitamin K to the newborn.
Determine obstetrical risk factors. - CORRECT Confirm the newborn's Apgar score:
- The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The
nurse should confirm the score when the newborn arrives in the nursery. However, there is another
action the nurse should take first.
ANS: Verify the newborn's identification:
- When using the safety/risk reduction approach to client care, the first action the nurse should take is to
verify the newborn's identity upon arrival to the nursery.
Administer vitamin K to the newborn:
- The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors
and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first
breastfeeding if necessary. Therefore, there is another action the nurse should take first.
Determine obstetrical risk factors:
- The nurse should identify obstetrical risk factors to determine if interventions are required for the
newborn. However, there is another action the nurse should take first.
Nurse is caring for patient who is in labor and reports increasing rectal pressure. Experiencing
contractions 2-3 min apart, each lasting 80-90 secs, and a vag exam reveals that her cervix is dilated 9
cm. Nurse should ID that patient is in which phases of labor?
,Active
Transition
Latent
Descent - CORRECT Active:
- The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3
to 5 min, each lasting 40 to 70 seconds.
ANS: Transition:
- The nurse should identify that the client is in the transition phase of labor. This phase is characterized
by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.
Latent:
- The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to
30 min, each lasting 30 to 45 seconds.
Descent:
- The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each
lasting for 90 seconds.
Nurse is teaching patient who is at 24 weeks gestation regarding a 1 hr glucose tolerance test. Which
statements should nurse include in teaching?
"You will need to drink the glucose solution 2 hours prior to the test."
"Limit your carbohydrate intake for 3 days prior to the test."
"A blood glucose of 130 to 140 is considered a positive screening result."
"You will need to fast for 12 hours prior to the test." - CORRECT "You will need to drink the glucose
solution 2 hours prior to the test.":
,- The nurse should instruct the client to drink the glucose solution 1 hr prior to the test.
"Limit your carbohydrate intake for 3 days prior to the test.":
- The nurse should instruct the client that she should not limit her carbohydrate intake.
ANS: "A blood glucose of 130 to 140 is considered a positive screening result.":
- The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a
positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose
tolerance test to confirm if she has gestational diabetes mellitus.
"You will need to fast for 12 hours prior to the test.":
- The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.
Nurse is assessing patient who gave birth vaginally 12 hrs ago and palpates her uterus to right above
umbilicus. Which interventions should the nurse perform?
Reassess the client in 2 hr.
Administer simethicone.
Assist the client to empty her bladder.
Instruct the client to lie on her right side. - CORRECT Reassess client in 2 hr:
- The nurse should assess the client more frequently after birth to determine the position of the uterus
and to intervene as soon as possible if necessary.
Administer simethicone:
- The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive
gas.
, ANS: Assist the client to empty her bladder:
- The nurse should assist the client to empty her bladder because the assessment findings indicate that
the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased
vaginal bleeding or postpartum hemorrhage.
Instruct the client to lie on her right side:
- Lying on her right side will not resolve the client's displaced uterus.
Nurse calculating a patient's expected DOB using nagele's rule. Client tells nurse that her last menstrual
cycle started on Nov 27th. Which dates is the patient expected DOB?
September 3rd
September 20th
August 3rd
August 20th - CORRECT ANS: September 3rd:
- When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract
3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th
minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.
September 20th:
- When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract
3 months from the first day of the client's last menstrual cycle and then add 7 days. Therefore, the
correct date is September 3rd.
August 3rd:
-"
August 20th:
