a nurse is assessing a client who is in active labor the client reports the urge to have a bowel movement and begins to bear down during contractions
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ATI Capstone Maternal Newborn Assessment Quizlet

1. A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.

2. A nurse is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B because facial swelling can indicate preeclampsia, a serious condition during pregnancy that requires immediate medical attention. Constipation (choice A), heartburn (choice C), and frequent urination (choice D) are common discomforts during pregnancy and are not typically indicative of a serious complication like preeclampsia at 32 weeks of gestation.

3. A nurse is teaching a client who is at 20 weeks of gestation about the glucose tolerance test. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C. During a glucose tolerance test, the client is required to drink a glucose solution, and blood samples are taken at specific intervals, typically over a period of 1 to 3 hours. In this case, the nurse should inform the client to expect the test to take about 1 hour. Choices A, B, and D are incorrect because there is no specific instruction to eat a low-carbohydrate diet for 3 days before the test, fast for 12 hours before the test, or limit fluid intake to water before the test in a standard glucose tolerance test.

4. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.

5. A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?

Correct answer: D

Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.

Similar Questions

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?
A nurse is assessing a newborn who was delivered 6 hours ago. Which of the following findings should the nurse report to the provider?
A client who is 12 weeks pregnant and experiencing nausea and vomiting is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?
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 client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?

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