ATI Maternal Newborn final questions with correct answers

nurse is planning care for a requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include inthe plan of careCorrect answer - Ensure the newborns eyes are closed before applying the eye shield - Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield. A nurse is caring for a client at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the patient is the priority?Correct answer - "My heart feels as if it is racing." - the nurse should assess the client's heart rate. The primary action of terbutaline is to cause bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?Correct answer - At 28 weeks of gestation - The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production. A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care?Correct answer - Check the cervix prior to analgesic administration. - Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn