ATI RN Maternal Newborn level 3 Final Answers Graded A+

ATI RN Maternal Newborn level 3 Final Answers Graded A+ A nurse is assessing a client who is at 34 weeks gestation and has a mild placental abruption. Which finding should the nurse expect? - Dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding. A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? Betamethasone Misoprostol Methylergonovine Poractant alfa - Betamethasone (to stimulate fetal lung maturity and prevent respiratory depression) A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which finding should the nurse include in the teaching? - Vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor. A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which finding should the nurse expect? - Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios. A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which adverse effect should the nurse include in the teaching? - Feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing (BP decreases b/c of magnesium, generalized prates could mean an allergic reaction) A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational hypertension. Which finding should the nurse identify as priority? - 480 mL urine output in 24 hours Low urine output (<30mL per hour) When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of hypertension, which requires immediate intervention. Therefore, this is the priority finding. A nurse is teaching a client who is at 12 weeks of gestation about the manifestations of potential complications that she should report to her provider. Which information should the nurse include in the teaching? - Swelling of the face The nurse should instruct the client to report swelling of the face because this can indicate a hypertensive disorder or preeclampsia A nurse is reviewing lab results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type of O negative. Which action should the nurse take? - Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery. A nurse is caring for a client who has oligohydramnios. Which fetal anomaly should the nurse expect? - Renal agenesis Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios. A nurse is caring for a client who believes she may be pregnant. Which finding should the nurse identify as a positive sign of pregnancy? - Palpable fetal movement Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy. A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. What finding should the nurse expect? - Uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma. A nurse is caring for a client at 26 weeks of gestation and reports constipation. How should the nurse respond? - "You should walk for at least 30 min/day" The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which action should the nurse take? - Apply pressure to the client's sacral area during contractions The nurse should provide counter pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain. A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which finding should the nurse report to the provider?