ATI Maternal Newborn Exam Q & A with Rationales Graded A+ 2023

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? Painless red vaginal bleeding Answer Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? Document the findings and continue to monitor the client. Answer Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? Dry the skin. Answer Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing action after securing the airway. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? Answer Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? Shortly after giving birth Answer Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome. A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? Clear the respiratory tract. Answer Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following delivery. A nurse in a family planning clinic is caring for a 17-year-old female client who is make? "What part of the exam makes you most nervous?" Answer Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? Two arteries and one vein Answer Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? An intrauterine device (IUD) Answer Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? The client requires a rubella immunization following delivery. Answer Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? Initiate IV access. Answer Rationale: 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? Excessive uterine enlargement Answer Rationale: A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia. A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? "This occurs because newborns lack muscle control to regulate eye movement." Answer Rationale: This addresses the client’s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? Offer the client a snack of orange juice and crackers. Answer Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement.