2024 ATI Materna Newborn Exam 2 Test Latest New
Updated Version with All Questions and 100%
Correct Answers
Question 1:
A nurse is assessing a client
... [Show More] who is at 32 weeks of gestation and is receiving
magnesium sulphate via continuous IV infusion. Which of the following
findings should the nurse report to the provider?
A. Decrease in frequency of contractions
B. BP 150/100 mm Hg
C. Absent deep tendon reflexes
D. Urinary output 35 mL/hr
Show correct answer and explanation
Explanation
Absent deep tendon reflexes are a sign of magnesium toxicity, which can occur
with high levels of magnesium in the bloodstream. This can be a serious
complication that requires immediate attention from the provider.
Option A, a decrease in the frequency of contractions, is actually a desired effect
of magnesium sulfate in the management of preterm labor. It is not a cause for
concern.
Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not
necessarily related to the administration of magnesium sulfate. However, it
should still be reported to the provider for appropriate management.
Option D, a urinary output of 35 mL/hr, is below the normal range but it may still
be within an acceptable range for a client receiving magnesium sulfate. The
provider should be notified if urinary output continues to decrease or if it falls
below a certain threshold.
Out of the listed findings, the nurse should report c. Absent deep tendon
reflexes to the provider immediately.
While the other findings may warrant monitoring or further assessment, they are
not immediately concerning in this context:
• a. Decrease in frequency of contractions:This could be a normal response
to magnesium sulfate, which is sometimes used to stop preterm labor.
However, it's important to monitor the contractions to ensure they don't
become too infrequent.
• b. BP 150/100 mm Hg:This is mildly elevated blood pressure, but not severe
enough to require immediate intervention in this case. Monitoring blood
pressure is still important, though.
• d. Urinary output 35 mL/hr:This is on the lower end of normal, but not
concerning enough to require immediate action. Monitoring urine output is
important to assess kidney function.
Absent deep tendon reflexes, however, is a sign of magnesium toxicity.
Magnesium sulfate is a medication that needs to be closely monitored because
high levels can be dangerous. If the nurse detects this finding, they should report
it to the provider right away so that magnesium levels can be checked and
appropriate action can be taken.
Here are some additional things to keep in mind:
• This is not an exhaustive list of all potential side effects of magnesium
sulfate.
• It is important for the nurse to follow the provider's orders and protocols for
monitoring clients receiving magnesium sulfate.
• If the nurse has any concerns about the client's condition, they should
always err on the side of caution and report them to the provider.
Question 2:
A nurse is teaching a client and her partner about the technique of
counterpressure during labor. Which of the following statements by the nurse
is appropriate?
A. “Your partner will apply pressure to the top of your uterus during contractions.”
B. “Your partner will apply steady pressure with a tennis ball to your lower
back.”
C. “Your partner will apply continuous, firm pressure between your thumb and
index finger.”
D. “Your partner will apply upward pressure on your lower abdomen between
contractions.”
Show correct answer and explanation
Explanation
Counterpressure is a technique that involves applying pressure to specific areas
of the body during labor to help alleviate pain and discomfort. This technique is
particularly helpful during the active phase of labor when contractions are strong
and painful. The most common area to apply counterpressure is the lower back,
as this is where many women experience the most intense pain during labor.
Option a, “Your partner will apply pressure to the top of your uterus during
contractions” is incorrect as applying pressure to the top of the uterus is not a
recommended technique and could be harmful to the mother and the baby.
Option c, “Your partner will apply continuous, firm pressure between your thumb
and index finger” is incorrect as this technique is used to alleviate pain and
discomfort during contractions in the hand and wrist, not for counterpressure.
Option d, “Your partner will apply upward pressure on your lower abdomen
between contractions” is incorrect as this technique is used to help turn a baby
who is in a posterior position, not for counterpressure. [Show Less]