a nurse is caring for a newborn who was delivered at 41 weeks of gestation which of the following findings is an indication of fetal postmaturity
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ATI Capstone Maternal Newborn Assessment Quizlet

1. A newborn delivered at 41 weeks of gestation is showing signs of postmaturity. Which of the following findings is an indication of fetal postmaturity?

Correct answer: C

Rationale: The correct answer is C: 'Thin with loose skin.' Postmature newborns are typically thin with loose skin due to prolonged gestation. This may result from placental insufficiency, leading to reduced subcutaneous fat stores. Choices A, B, and D are incorrect. Soft, flexible ear cartilage (choice A) is a normal finding in newborns. Smooth soles without creases (choice B) are also typical in newborns. Vernix caseosa covering the body (choice D) is a protective, waxy coating found on newborns, which may be present in postmature infants as well.

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 client in the first stage of labor is experiencing lower back pain and asks the nurse what can be done to relieve the pain. Which of the following interventions should the nurse suggest?

Correct answer: B

Rationale: Applying counterpressure to the sacrum can help alleviate lower back pain during labor by reducing pressure on the nerves. Effleurage on the abdomen, back massage with lavender oil, and administering opioid analgesics are not specifically targeted at relieving lower back pain, making them less effective interventions in this scenario.

4. 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.

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.

Similar Questions

A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?
A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?
A healthcare provider is assessing a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. Which of the following findings indicates magnesium toxicity?
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?
A nurse is caring for a client who is receiving oxytocin for labor induction. Which of the following findings requires immediate intervention?

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