LPN LPN
ATI Maternal Newborn
1. A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?
- A. Peanut butter
- B. Potatoes
- C. Apple juice
- D. Broccoli
Correct answer: A
Rationale: Individuals with phenylketonuria (PKU) have difficulty breaking down phenylalanine, an amino acid found in protein-rich foods like peanut butter. Therefore, clients with PKU should avoid foods high in phenylalanine, such as peanut butter, to prevent adverse effects on their health. Choices B, C, and D are not typically high in phenylalanine and do not pose the same risk to individuals with PKU as peanut butter.
2. A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?
- A. Hand the parent the newborn and suggest that they change the diaper.
- B. Ask the parent why they are so anxious and nervous.
- C. Tell the parent that they will grow accustomed to the newborn.
- D. Provide reinforcement about infant care when the parent is present.
Correct answer: D
Rationale: Providing reinforcement about infant care when the parent is present can help alleviate anxiety and promote positive parent-infant bonding. By offering guidance and support while the parent is interacting with the newborn, the nurse can help build the parent's confidence and strengthen the bond between the parent and the infant. Choice A is not ideal as it does not address the parent's anxiety and may increase stress levels. Choice B focuses on the parent's emotions without providing direct support for bonding. Choice C is dismissive and does not offer practical assistance in fostering bonding between the parent and the infant.
3. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct answer: B
Rationale: The priority action for the nurse in this situation is to position the client with one hip elevated. This position can help improve blood flow to the placenta and stabilize blood pressure, which is crucial for both the client and the fetus during labor. It can also help optimize fetal oxygenation by improving circulation. Notifying the provider of the findings may be necessary, but ensuring proper positioning of the client takes precedence to address the immediate physiological needs. Asking the client about pain medication or having the client void are important interventions but are not the priority in this scenario where the client is experiencing painful contractions and has low blood pressure.
4. A client who is breastfeeding and has mastitis is receiving teaching from the nurse. Which of the following responses should the nurse make?
- A. Limit the amount of time the infant nurses on each breast.
- B. Nurse the infant only on the unaffected breast until resolved.
- C. Completely empty each breast at each feeding or use a pump.
- D. Wear a tight-fitting bra until lactation has ceased.
Correct answer: C
Rationale: The correct response is to completely empty each breast at each feeding or use a pump to prevent milk stasis, which can exacerbate mastitis. By ensuring proper drainage of the affected breast, the client can help alleviate symptoms and promote healing. Choice A is incorrect because limiting feeding time can lead to inadequate drainage, potentially worsening the condition. Choice B is incorrect as it can cause engorgement in the unaffected breast, leading to further complications. Choice D is incorrect as wearing a tight-fitting bra can worsen symptoms by putting pressure on the affected breast, hindering proper drainage and exacerbating mastitis.
5. While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?
- A. Conjunctivitis
- B. Bronze skin discoloration
- C. Sunken fontanels
- D. Maculopapular skin rash
Correct answer: C
Rationale: Sunken fontanels should be prioritized for reporting as they indicate dehydration, which is a critical concern in infants undergoing phototherapy. Dehydration can lead to serious complications, making it essential for the nurse to promptly inform the charge nurse for appropriate intervention and management. Conjunctivitis, bronze skin discoloration, and maculopapular skin rash are important findings to note, but in this scenario, sunken fontanels take precedence due to the potential severity of dehydration in infants.
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