ATI RN Maternal Newborn Online Practice 2019 A, RN Maternal Newborn Online Practice 2019 B - ATI

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ATI RN Maternal Newborn Online Practice 2019 A, RN Maternal Newborn Online Practice 2019 B - ATI A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon... reviewing the client's medical record, which of the following findings should the nurse report to the provider? 1-Hr Glucose Tolerance Test - 120 mg/dL Hematocrit - 34% Fundal Height Measurement - 30 cm Fetal Heart Rate - 110 bpm ✔Ans✔ Fundal Height A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. 1-Hr GTT of 130-140 or greater indicates a need to report to provider. Hematocrit above 33% is normal FHR is normal (110-160/min) A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed ✔Ans✔ RR 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Flushing and nausea are expected, but oliguria (levels of 25-30 mL/hr or less) is a sign of toxicity. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum ✔Ans✔ Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Everything else is expected A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurses priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring. ✔Ans✔ Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse (this is a common test question--Remember, cord compression is associated with variable decelerations and can happen after ROM). The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. Other actions are correct, but not priority. A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (select all that apply) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible ✔Ans✔ Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. [Show More]

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