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Maternal Newborn ATI Quizlet
1. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?
- A. Perform a sharp hand clap near the infant.
- B. Hold the newborn vertically allowing one foot to touch the table surface.
- C. Place a finger at the base of the newborn's toes.
- D. Turn the newborn's head quickly to one side.
Correct answer: A
Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.
2. During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?
- A. Vertex
- B. Shoulder
- C. Breech
- D. Mentum
Correct answer: C
Rationale: The correct answer is C: "Breech." The RSA position indicates that the fetus is in a breech presentation. In a breech presentation, the buttocks or feet are positioned to be delivered first, which can impact the mode of delivery and require close monitoring during labor and birth. Choice A (Vertex) refers to the head-first presentation, which is considered the normal and most common presentation for birth. Choice B (Shoulder) does not represent a specific fetal presentation. Choice D (Mentum) refers to the chin presentation, which is also not relevant in this scenario.
3. A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?
- A. Evaluate the firmness of the uterus.
- B. Initiate oxygen therapy via a non-rebreather mask.
- C. Administer oxytocin infusion.
- D. Obtain a type and crossmatch.
Correct answer: A
Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.
4. During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?
- A. Acrocyanosis of hands and feet
- B. Anterior fontanel soft and level
- C. Plantar creases cover 2/3 of sole
- D. Vernix caseosa in inguinal creases
Correct answer: C
Rationale: Plantar creases covering 2/3 of the sole is an important physical characteristic used to assess gestational age in a newborn. This finding is significant because as gestational age advances, the plantar creases cover a larger portion of the sole. It is a valuable clue to the healthcare provider in determining the newborn's maturity level. Choices A, B, and D are incorrect as they do not specifically relate to gestational age assessment. Acrocyanosis and vernix caseosa are common findings in newborns but are not directly used for determining gestational age. The softness and level of the anterior fontanel can provide information about intracranial pressure but are not directly related to gestational age assessment.
5. A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct answer: B
Rationale: A surge of energy is a common sign that precedes labor. This burst of energy, often referred to as the 'nesting instinct,' is believed to occur as the body prepares for labor, prompting the individual to undertake tasks to prepare for the arrival of the baby. Decreased vaginal discharge is not a typical sign preceding labor. Urinary retention is not a sign that precedes labor and may indicate another issue. Weight gain of 0.5 to 1.5 kg is not a specific sign of impending labor.
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