a nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mgdl which of the following interventions should the nur
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Nursing Elites

ATI RN

ATI Capstone Maternal Newborn Assessment Quizlet

1. 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.

2. 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.

3. A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?

Correct answer: A

Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.

4. A client at 37 weeks of gestation is scheduled for a nonstress test. What information should the nurse include?

Correct answer: C

Rationale: The correct answer is C. Drinking orange juice before the nonstress test can increase fetal movement, which is essential for an accurate reading. Choice A is incorrect because oxytocin is not typically administered during a nonstress test. Choice B is incorrect as fasting is not required before this test. Choice D is incorrect as a full bladder is not necessary for a nonstress test.

5. 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.

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