1. Exhibit 1: Medical hx Respiratory findings is incorrect. The new-
Newborn delivered by repeat cesarean born's respiratory rate is within the expect-
birth at 40 weeks of gestation. Birth weight e Sd reference range of 30 to 60/min.
There
3,515 g (7 lb 12 oz) Apgar scores 8 at 1 is no indication the newborn has an al-
min and 9 at 5 min. Maternal history of teration in respiratory status; therefore, this
methadone use during pregnancy. finding does not need to be reported to the
Exhibit 2: VS provider.
@0700: Heart rate 156/min. Respiratory Temperature is incorrect. The newborn's
rate 58/min. Temperature 37.2° C (98.9° F) temperature is within the expected reference
Oxygen saturation 98% on room air range of 36.5° to 37.5° C (97.7° to 99.5° F).
@1100: Heart rate 160/min. Respiratory Therefore, this finding does not need to be
rate 60/min. Temperature 37.3° C (99.2° F) reported to the provider.
Oxygen saturation 96% on room air Oxygen saturation is incorrect. The new-
Exhibit 3: Phys Exam born's oxygen saturation is within the ex-
Newborn is inconsolable with a pected reference range of greater than 94%;
high-pitched cry. Newborn sucks vigorous- therefore, this finding does not need to be
ly on pacifier but breastfeeds poorly. Res- bright red blood in their
pirations unlabored. Lungs sound clear underwear upon
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 (-
2. Exhibit 1: RN note
@ 0900: Client reports a small amount of
, Grade A+ ATI RN Maternal Newborn A Exam 2025
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 exces- sive sucking.
These findings are manifesta- tions of NAS and should be reported
to the provider.
Gastrointestinal findings is correct. The new- born is displaying poor
feeding and loose stools. These findings are manifestations of NAS
and should be reported to the provider.
When generating solutions, inserting a large bore intravenous
catheter is indicat- ed. Clients who have third trimester vaginal
, Grade A+ ATI RN Maternal Newborn A Exam 2025
awakening. Client denies contractions or bleeding may experience a sudden hemor-
abdominal pain. External fetal monitor ap- rhage and require fluid resuscitation or the
plied. administration of blood products. The nurse
@0930: Client passed large amount of should weigh perineal pads. Weighing per-
bright red blood from vagina. Denies pain. ineal pads after use will provide a more accu-
Uterine tone soft and nontender to palpa- rate assessment of the volume of blood loss
tion. Contraction pattern: no contractions that the client is experiencing.
noted. Fetal heart rate pattern: Fetal heart
rate baseline 135/min. Moderate variabili- When generating solutions, the nurse
ty. No decelerations noted. should not administer methotrexate or as-
Exhibit 2: VS sess for cervical dilation because it is con-
@0900: Temperature 36.2°C (97.2° F)Pulse traindicated for this client. Methotrexate is
rate 78/min. Respiratory rate 20/min. an antimetabolite and folic acid antagonist
Blood pressure 112/64 mmHg. Fetal heart which destroys rapidly dividing cells. It can
rate 132/min be administered during pregnancy to med-
@0930: Pulse rate 82/min. Blood pressure ically resolve an ectopic pregnancy during
116/60 mmHg. Fetal heart rate 160/min the first trimester. Assessing cervical dilation
Exhibit 3: Medical hx is contraindicated for any pregnant client
G4P3. 30 weeks gestation. Previous preg- who is experiencing vaginal bleeding. Ma-
nancies delivered via cesarean section nipulation of the cervix during the exami-
nation may result in further damage to the
placenta and compromise the well-being of
the client and fetus.
3. A nurse is assessing the newborn of a d. Vomiting
client who took selective serotonin re-
uptake inhibitor (SSRI) during pregnan- Expected manifestations associated with fe-
cy. Which of the following manifestations tal exposure to SSRIs include irritability,
should the nurse identify as an indication agitation, tremors, diarrhea, and vomiting.
of withdrawal from an SSRI? These manifestations typically last 2 days.
a. Large for gestational age
b. Hyperglycemia