ati capstone maternal newborn assessment quizlet ATI Capstone Maternal Newborn Assessment Quizlet - Nursing Elites
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Nursing Elites

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ATI Capstone Maternal Newborn Assessment Quizlet

1. A nurse is caring for a client who is postpartum and breastfeeding. Which of the following instructions should the nurse provide to prevent mastitis?

Correct answer: D

Rationale: To prevent mastitis, the nurse should instruct the client to ensure that the newborn empties one breast before switching to the other. This helps to prevent milk stasis, reducing the risk of inflammation and infection. Choice A is incorrect because feeding on demand is recommended to establish a good milk supply and prevent engorgement. Choice B is incorrect as warm compresses are usually applied before feeding to promote milk flow. Choice C is incorrect because massaging the breast after feedings can actually increase the risk of mastitis by causing further irritation.

2. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.

3. A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.

4. A nurse is providing care to a client who is in active labor. The nurse observes variable decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct action the nurse should take first when observing variable decelerations in the fetal heart rate is to reposition the client from side to side. Variable decelerations are often caused by umbilical cord compression, and repositioning the client can relieve pressure on the cord. Administering oxygen, increasing the IV infusion rate, and notifying the provider can be appropriate actions but repositioning the client takes priority in addressing variable decelerations.

5. A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.

Similar Questions

A nurse is providing discharge teaching to a client who is postpartum and had a cesarean birth. Which of the following instructions should the nurse include?
A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?
A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?
A nurse is assessing a client who is at 34 weeks of gestation and is receiving magnesium sulfate for severe preeclampsia. Which of the following findings should the nurse report to the provider?
A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?
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