ATI PROCTORED EXAM - MATERNAL NEWBORN

ATI PROCTORED EXAM - MATERNAL NEWBORN A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? - . Use a photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective. A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? - Dark red vaginal bleeding The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal bleeding. A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? - Correct Answer: Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia. Incorrect Answers: The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal perforation. Instead, the nurse should obtain an axillary temperature. Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? - Correct Answer: Calcium gluconate The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest. Incorrect Answers: . Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate. . Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not magnesium sulfate. A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? - Correct Answer: "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted. Incorrect Answers: . The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement and swelling. . Application of warmth to the breasts should be avoided because heat can stimulate milk production. An ice pack should be used to relieve engorged breasts. . Milk should not be expressed from the breasts. This intervention would increase milk production rather than decrease it. A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? - Correct Answer: "You should eat dry foods that are high in carbohydrates when you wake up." The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or crackers upon waking or when nausea occurs. Incorrect Answers: The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and vomiting. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease vomiting. . The nurse should instruct the client to eat salty and tart foods during periods of nausea.