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 pr
Logo

Nursing Elites

ATI RN

ATI Capstone Maternal Newborn Assessment Quizlet

1. 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.

2. A nurse is providing discharge teaching to a client who is postpartum and has a prescription for ibuprofen for perineal pain. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Take the medication with food.' Ibuprofen can cause gastrointestinal upset, so it is essential for the client to take the medication with food to minimize this side effect. Choice A, 'Take the medication on an empty stomach,' is incorrect because ibuprofen should be taken with food to prevent stomach irritation. Choice B, 'Take the medication only at bedtime,' is incorrect as there is no specific timing requirement for ibuprofen administration related to bedtime. Choice D, 'Take the medication with caffeine,' is incorrect as there is no benefit in combining ibuprofen with caffeine, and caffeine could potentially worsen gastrointestinal side effects.

3. A client who is breastfeeding is receiving teaching from a nurse. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for the nurse to include is to offer both breasts at each feeding. This practice helps ensure the baby receives hindmilk from both breasts, promoting adequate milk intake and stimulating milk production. Option A is incorrect as newborns should be breastfed on demand rather than on a strict schedule. Option C is inappropriate as it can interfere with establishing and maintaining a sufficient milk supply. Option D is inaccurate as newborns typically do not sleep through the night at one month; they need to feed frequently for proper growth and development.

4. 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.

5. 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.

Similar Questions

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?
A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?
A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?
A nurse is caring for a newborn who is large for gestational age (LGA). Which of the following findings should the nurse expect?
A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses