ATI MATERNITY DETAILED PRACTICE ANSWER KEY UPDATED FOR 2019-2024 FAMILY CHILD NURSING (BRYANT & STRATTON COLLEGE) QUESTIONS AND CORRECT ANSWERS
1. A
... [Show More] client at 40 weeks of gestation is about to undergo a biophysical profile. The nurse should explain that this profile focuses on which of the following parameters? (Select all that apply.)
A. Fetal breathing
B. Fetal motion
C. Nuchal translucency
D. Amniotic fluid volume
E. Fetal gender
Rationale: Fetal breathing is correct. A biophysical profile includes evaluation of fetal breathing
movements.
Fetal motion is correct. A biophysical profile includes evaluation of gross body
movement of the fetus.
Nuchal transparency is incorrect. This screening technique measures fluid in the nape of the fetal neck via ultrasound, but it is not a parameter of the biophysical profile.
Amniotic fluid volume is correct. A biophysical profile includes a qualitative
evaluation of amniotic fluid volume.
Fetal gender is incorrect. Although ultrasonography can determine gender, the
biophysical profile measures fetal well-being, not gender.
2. A client delivered a 34-week, 1,550-g newborn who has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral thermal environment because
A. he has a small body surface for his weight.
Rationale: Preterm newborns have a large body surface area for their weight.
B. heat increases flow of oxygen to his extremities.
Rationale: The goal is not simply to expose the infant to heat, but to an environment that avoids not just hypothermia, but hyperthermia as well. In a neutral thermal environment, oxygen consumption is minimal. Both hypothermia and hyperthermia can adversely affect oxygenation.
C. his temperature control mechanism is immature.
Rationale: Preterm newborns have poor body control of temperature and needs immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity. They require an external heat source that regulates their immediate environment via a sensor attached to the skin.
D. heat facilitates the drainage of mucus.
Rationale: Dry heat can impede the drainage of mucus.
3. A nurse is caring a client who is 1 day postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?
A. Swelling in both breasts
Rationale: Because the swelling is present in both breasts and there is no redness or pain, this client is not likely to have mastitis. This client is more likely to have engorgement.
The nurse should assist the client to breastfeed frequently and use a well-fitting bra. It also might help to use warmth, such as a warm shower. If the breasts are severely engorged, it might help to express some milk to soften the breasts prior to nursing.
B. Cracked and bleeding nipples
Rationale: Cracked and bleeding nipples are not signs of mastitis. However, cracked nipples are a risk for developing mastitis. Cracked and sore nipples may occur until the woman’s nipples adapt to the friction from nursing. Cracked and sore nipples also may indicate tissue damage from inadequate latching. The nurse should reinforce appropriate breastfeeding techniques.
C. Red and painful area in one breast
Rationale: Mastitis often appears as a red, hard, and painful area. Although mastitis may occur in both breasts, it is usually unilateral. After delivery, the nurse should monitor a woman’s breasts for signs of mastitis and reinforce instruction for breast self- examination.
D. Temperature of 380 C (1000 F)
Rationale: A client may have an elevated temperature during the initial 24 hr postpartum. This is due to fluid loss during labor and delivery, sleep deprivation, and physiologic response to the birthing process. A temperature that persists after 24 hr postpartum may indicate an infection.
4. A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for postpartal hemorrhage due to uterine atony because she had a
A. midline episiotomy.
Rationale: A midline episiotomy does not cause uterine atony.
B. precipitous delivery.
Rationale: The risk of uterine atony increases whenever the uterus has been overstressed or overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr).
C. vaginal delivery.
Rationale: The risk of hemorrhage does not increase after an uncomplicated vaginal delivery.
D. periurethral tear.
Rationale: This injury does not increase the risk of uterine atony.
5. A nurse is collecting data on a newborn that is 48 hr old. Which of the following findings should the nurse report to the provider?
A. Telangiectatic nevi
Rationale: Telangiectatic nevi are also known as “stork bites” and are pink in appearance and blanch easily. They commonly appear on the upper lip, upper eyelids, nose, nape of the neck, and lower occiput bone. This finding has no clinical significance.
B. Erythema toxicum
Rationale: Erythema toxicum is a transient rash appearing during the first 3 weeks of age. The lesions appear at various stages: erythematous macules, papules, and small vesicles. This finding has no clinical significance.
C. Generalized petechiae
Rationale: Generalized petechiae may indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation.
D. Mongolian spot
Rationale: Mongolian spots are bluish black areas which commonly appear over the back or buttocks. They are frequently seen in Latin America, African, or Asian newborns. This finding has no clinical significance.
6. A nurse who is caring for a newborn observes signs of diaphoresis, jitteriness, and lethargy. Which of the following is the appropriate nursing action?
A. Obtain blood glucose by heel stick.
Rationale: The newborn is exhibiting early signs of hypoglycemia. Other signs of hypoglycemia include poor feeding, tremors, hypothermia, flaccid muscle tone, irregular respirations, apnea, cyanosis, and a weak shrill cry. The nurse should obtain blood by heel stick to check glucose. A therapeutic serum glucose level for a newborn is 40-60 mg/dL. Less than 35 mg/dL would indicate hypoglycemia. The newborn can be treated with frequent oral and/or gavage feedings or continuous parenteral nutrition. Early breastfeeding also should be encouraged to prevent hypoglycemia. Untreated hypoglycemia can lead to seizures, brain damage, and/or death.
B. Initiate phototherapy.
Rationale: The newborn is exhibiting signs of hypoglycemia. Phototherapy would be initiated for a newborn with hyperbilirubinemia. The newborn would exhibit jaundice and a bilirubin level of 5 to 7 mg/dL.
C. Measure the newborn’s blood pressure.
Rationale: This is not the best action. The newborn is exhibiting signs of hypoglycemia. The nurse’s initial action should be to obtain a blood glucose level. Treatment of the hypoglycemia is the priority.
D. Place the newborn in a radiant warmer.
Rationale: The newborn is exhibiting early signs of hypoglycemia. The newborn should be placed in a radiant warmer to prevent hypothermia. The appropriate response is to obtain a blood glucose level and treat the hypoglycemia.
7. A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?
A. A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful.
Rationale: This is not an unexpected finding. This client may be experiencing premature labor due to the irregular contractions. A client in preterm labor would be concerned about the welfare of her infant. The nurse should provide psychosocial support and opportunities for the woman and family to express feelings and concerns. However, the psychosocial aspect would not be the priority in this situation.
B. A client who is at 28 weeks of gestation and receiving terbutaline (Brethine) reports fine tremors.
Rationale: Terbutaline (Brethine) is a beta□-adrenergic agonist used occasionally in preterm labor to decrease uterine contractions. It relaxes smooth muscles, inhibiting uterine activity and causing bronchodilation. The most common side effects include tachycardia, chest discomfort, palpitations, tremors, dizziness, nervousness, headache, nasal congestion, nausea and vomiting, hypokalemia, hyperglycemia, and hypotension. Intolerable adverse effects include maternal heart rate greater than 130/min, BP less than 90/60 mm Hg, chest pain, arrhythmias, signs of pulmonary edema, and FHR greater than 180/min. Propranolol (Inderal) should be available to reverse adverse effects related to cardiovascular function. Fine tremors are an expected side effect and would not need to be reported immediately.
C. A client who has a diagnosis of preeclampsia has 2+ patellar reflexes and 2+ proteinuria.
Rationale: These are expected findings in mild preeclampsia. Signs and symptoms associated with mild preeclampsia include blood pressure of 140/90 mm Hg or greater, or a systolic increase of 30 mm Hg and diastolic increase of 15 mm Hg, and 1 to 2+ proteinuria. Reflexes that are 2+ are normal.
D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache.
Rationale: These symptoms indicate that the client’s condition is worsening and are symptoms of severe preeclampsia. Signs and symptoms of severe preeclampsia include the following:
• Blood pressure of 160/100 mm Hg or greater
• Proteinuria 3 to 4+
• Oliguria
• Elevated serum creatinine greater than 1.2 mg/dL
• Cerebral or visual disturbances (headache and blurred vision)
• Hyperreflexia with possible ankle clonus
• Pulmonary, cardiac, or hepatic involvement including elevated liver enzymes, nausea, vomiting, epigastric pain, and right upper-quadrant pain
• Extensive peripheral edema
• Thrombocytopenia
8. A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client’s need to urinate?
A. Moderate lochia rubra
Rationale: Moderate lochia rubra is an expected finding 8 hr after delivery and does not correlate with a full bladder.
B. Fundus three finger breaths above the umbilicus
Rationale: A full bladder can raise the level of uterine fundus and possibly deviate it to the side.
C. Moderate swelling of the labia
Rationale: Swelling in the perineal area is an expected finding after a vaginal delivery and does not correlate with a full bladder.
D. Blood pressure 130/84 mm Hg
Rationale: The client’s blood pressure after delivery does not correlate with a full bladder.
9. A client has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. The nurse’s priority action is to
A. suction the nose with a bulb syringe.
Rationale: Suctioning the secretions from the nose is important, but it is not the first action the nurse should take. Touching the nares with the tip of the bulb syringe might make the newborn gasp and inhale secretions from the mouth.
B. suction the mouth with a bulb syringe.
Rationale: The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.
C. use a suction catheter with low negative pressure.
Rationale: It may become necessary to remove secretions that interfere with respiratory effort using a mechanical suction system, but this is not the first action the nurse should take.
D. turn the newborn on his side.
Rationale: Positioning a newborn with excessive secretions on the side with a rolled blanket supporting the back is important to help prevent aspiration, but it is not the first action the nurse should take.
10. A nurse is planning to reinforce teaching to a group of pregnant clients regarding management of constipation during pregnancy. Which of the following statements should the nurse include in the content?
A. “Use mineral oil to relieve constipation.”
Rationale: Clients should not use mineral oil to relieve constipation during pregnancy.
B. “Drink 1 L of water daily to decrease constipation.”
Rationale: Clients should drink 2 to 3 L of fluid from food and beverage sources per day to relieve constipation.
C. “Use an enema when constipation occurs.”
Rationale: Clients should not use enemas to relieve constipation during pregnancy.
D. “Eat an apple to help with constipation.”
Rationale: Constipation is a common discomfort occurring during pregnancy that results from relaxation of gastrointestinal (GI) muscle tone and motility related to increased progesterone levels, increased pressure of the GI tract by the fetus, and use of iron supplements. The nurse should teach the client to increase dietary roughage such as fruits, vegetables, and legumes which are excellent sources of fiber. [Show Less]