ATI RN Maternal
Newborn A
,Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight
3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of
methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier
but breastfeeds poorly. Respirations unlabored. Lungs sound clear 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 (- - CORRECT ANSWERS-Respiratory findings is incorrect.
The newborn's respiratory rate is within the expected reference range of 30 to 60/min.
There is no indication the newborn has an alteration in respiratory status; therefore, this
finding does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected
reference range of greater than 94%; therefore, this finding does not need to be
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
excessive sucking. These findings are manifestations of NAS and should be reported to
the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose
stools. These findings are manifestations of NAS and should be reported to the
provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
@0930: Client passed large amount of bright red blood from vagina. Denies pain.
Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood
pressure 112/64 mmHg. Fetal heart rate 132/min
, @0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min
Exhibit 3: Medical hx
G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section -
CORRECT ANSWERS-When generating solutions, inserting a large bore intravenous
catheter is indicated. Clients who have third trimester vaginal bleeding may experience
a sudden hemorrhage and require fluid resuscitation or the administration of blood
products. The nurse should weigh perineal pads. Weighing perineal pads after use will
provide a more accurate assessment of the volume of blood loss that the client is
experiencing.
When generating solutions, the nurse should not administer methotrexate or assess for
cervical dilation because it is contraindicated for this client. Methotrexate is an
antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be
administered during pregnancy to medically resolve an ectopic pregnancy during the
first trimester. Assessing cervical dilation is contraindicated for any pregnant client who
is experiencing vaginal bleeding. Manipulation of the cervix during the examination may
result in further damage to the placenta and compromise the well-being of the client and
fetus.
A nurse is assessing the newborn of a client who took selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the
nurse identify as an indication of withdrawal from an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting - CORRECT ANSWERS-d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client's history should the nurse
recognize as a contraindication to oral contraceptives? (Select all that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder - CORRECT ANSWERS-Cholecystitis, hypertension, and migraine
headaches is correct. A history of gallbladder disease is a contraindication for the use of
oral contraceptives. Hypertension is a contraindication for the use of oral
contraceptives. A history of migraine headaches is a contraindication for the use of oral
contraceptives.
HPV and anxiety disorder is incorrect. The presence of human papillomavirus is not a
contraindication for the use of oral contraceptives. The presence of an anxiety disorder
is not a contraindication for the use of oral contraceptives.
Newborn A
,Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight
3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of
methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier
but breastfeeds poorly. Respirations unlabored. Lungs sound clear 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 (- - CORRECT ANSWERS-Respiratory findings is incorrect.
The newborn's respiratory rate is within the expected reference range of 30 to 60/min.
There is no indication the newborn has an alteration in respiratory status; therefore, this
finding does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected
reference range of greater than 94%; therefore, this finding does not need to be
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
excessive sucking. These findings are manifestations of NAS and should be reported to
the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose
stools. These findings are manifestations of NAS and should be reported to the
provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear upon
awakening. Client denies contractions or abdominal pain. External fetal monitor applied.
@0930: Client passed large amount of bright red blood from vagina. Denies pain.
Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted.
Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood
pressure 112/64 mmHg. Fetal heart rate 132/min
, @0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min
Exhibit 3: Medical hx
G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section -
CORRECT ANSWERS-When generating solutions, inserting a large bore intravenous
catheter is indicated. Clients who have third trimester vaginal bleeding may experience
a sudden hemorrhage and require fluid resuscitation or the administration of blood
products. The nurse should weigh perineal pads. Weighing perineal pads after use will
provide a more accurate assessment of the volume of blood loss that the client is
experiencing.
When generating solutions, the nurse should not administer methotrexate or assess for
cervical dilation because it is contraindicated for this client. Methotrexate is an
antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be
administered during pregnancy to medically resolve an ectopic pregnancy during the
first trimester. Assessing cervical dilation is contraindicated for any pregnant client who
is experiencing vaginal bleeding. Manipulation of the cervix during the examination may
result in further damage to the placenta and compromise the well-being of the client and
fetus.
A nurse is assessing the newborn of a client who took selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the
nurse identify as an indication of withdrawal from an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting - CORRECT ANSWERS-d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client's history should the nurse
recognize as a contraindication to oral contraceptives? (Select all that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder - CORRECT ANSWERS-Cholecystitis, hypertension, and migraine
headaches is correct. A history of gallbladder disease is a contraindication for the use of
oral contraceptives. Hypertension is a contraindication for the use of oral
contraceptives. A history of migraine headaches is a contraindication for the use of oral
contraceptives.
HPV and anxiety disorder is incorrect. The presence of human papillomavirus is not a
contraindication for the use of oral contraceptives. The presence of an anxiety disorder
is not a contraindication for the use of oral contraceptives.
