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Ati lpn maternal newborn 2023
Ati lpn maternal newborn 2023
Total Questions : 58
Showing 10 questions Sign up for moreA nurse is reviewing the facility protocol about newborn identification and safety with a new parent.
Which of the following information should the nurse include?
Explanation
Choice A rationale
Scanning the baby's identification bracelet each time staff checks on the baby ensures proper identification, but it is not the primary safety measure for parents to follow.
Choice B rationale
Parents should verify the identity of anyone taking the baby from the room. This prevents unauthorized individuals from removing the baby, enhancing security and safety.
Choice C rationale
Matching the bracelet with the footprint record each shift helps with identification, but it is a hospital staff responsibility, not something parents need to focus on.
Choice D rationale
While electronic bracelets provide additional security, they are not used exclusively when the baby is out of the room and do not replace the need for parents to check identities.
A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?
Explanation
Choice A rationale
Gallbladder disease does not directly contraindicate the use of an intrauterine device (IUD).
Choice B rationale
An IUD is contraindicated in clients with a positive pregnancy test because it can harm the developing fetus and lead to complications.
Choice C rationale
Smoking is a risk factor for cardiovascular issues but does not specifically contraindicate the use of an IUD.
Choice D rationale
Being nulliparous (having never given birth) is not a contraindication for IUD use; it may pose some challenges but is not a strict contraindication.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
Explanation
Choice A rationale
Fever is not a common adverse effect of nalbuphine hydrochloride; it may indicate an infection rather than a reaction to the medication.
Choice B rationale
Diarrhea is not typically associated with nalbuphine hydrochloride, which primarily affects the central nervous system.
Choice C rationale
Sedation is a known adverse effect of nalbuphine hydrochloride as it acts on the central nervous system to relieve pain, which can cause drowsiness.
Choice D rationale
Diuresis (increased urine production) is not a common side effect of nalbuphine hydrochloride.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
Explanation
Choice A rationale
Elevated maternal temperature indicates infection but is not as immediate a threat as compromised fetal heart tones.
Choice B rationale
Fetal heart tones at 98/min are significantly lower than the normal range (110-160/min), indicating fetal distress and requiring immediate intervention.
Choice C rationale
Foul-smelling discharge suggests infection but is not the priority compared to fetal distress.
Choice D rationale
Meconium-stained amniotic fluid indicates fetal distress but is less urgent compared to low fetal heart tones.
The nurse is collecting data from the client 24 hr later.
How should the nurse interpret the findings?
Explanation
Choice A rationale
Moderate lochia rubra is normal postpartum bleeding and does not indicate a worsening condition.
Choice B rationale
Decreased pain suggests recovery rather than deterioration.
Choice C rationale
A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.
Choice D rationale
An elevated WBC count indicates an immune response, which may suggest infection or inflammation, pointing to a worsening condition. .
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management.
The client's blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take?
Explanation
Choice A rationale
Placing the client in the knee-chest position is not appropriate for managing hypotension. This position is typically used for cord prolapse to relieve pressure on the umbilical cord, not for hypotension due to an epidural infusion.
Choice B rationale
Giving a bolus of lactated Ringer's solution can help increase the client's blood pressure by expanding the intravascular volume. This is a common and effective intervention for hypotension caused by epidural anesthesia.
Choice C rationale
Administering methylergonovine IM is inappropriate in this context because it is used to manage postpartum hemorrhage by stimulating uterine contractions, not for treating hypotension.
Choice D rationale
Assisting the client to empty her bladder might help in some situations but is not an immediate intervention for hypotension. The primary concern with epidural-induced hypotension is to restore adequate blood pressure quickly.
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum.
In which of the following positions should the nurse instruct the client to place their newborn in the crib?
Explanation
Choice A rationale
Placing a newborn in the supine position (on their back) is recommended to reduce the risk of sudden infant death syndrome (SIDS). This safe sleep practice has been proven to significantly lower the risk of SIDS.
Choice B rationale
Placing a newborn in the left lateral position is not recommended as the primary position for sleep, as it does not offer the same protective benefits against SIDS as the supine position.
Choice C rationale
Placing a newborn in the right lateral position similarly does not provide the same reduction in SIDS risk as the supine position. Side-lying positions can lead to rolling into a prone position, increasing the risk.
Choice D rationale
Placing a newborn in the prone position (on their stomach) is associated with a higher risk of SIDS. This position is not recommended for sleep due to the increased risk of respiratory compromise.
A nurse is collecting data from a newborn.
The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?
Explanation
Choice A rationale
The image showing toes fanning out when the sole of the foot is stroked demonstrates a positive Babinski reflex. This reflex is normal in newborns and indicates immature nervous system development.
Choice B rationale
The image showing the newborn grasping a finger when the palm is touched demonstrates the palmar grasp reflex, not the Babinski reflex. This reflex is also normal in newborns but is unrelated to the Babinski reflex.
Choice C rationale
The image showing the newborn turning the head when the cheek is stroked demonstrates the rooting reflex, not the Babinski reflex. This reflex helps the newborn locate the breast or bottle for feeding.
Choice D rationale
The image showing the newborn making stepping movements when held upright demonstrates the stepping reflex, not the Babinski reflex. This reflex mimics walking and is normal in newborns.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
Explanation
Choice A rationale
Encouraging the client to continue to breastfeed is recommended in cases of mastitis. Breastfeeding helps to empty the breast, which can reduce pain and inflammation and promote healing.
Choice B rationale
Preparing the client for an abdominal sonogram is unnecessary in the context of mastitis. Sonograms are typically used for diagnosing issues unrelated to mastitis, such as abdominal or pelvic conditions.
Choice C rationale
Wearing a loose-fitting bra may provide comfort, but it is not specifically recommended for managing mastitis. Proper support and continued breastfeeding are more critical for treatment.
Choice D rationale
Limiting the client's daily fluid intake is not recommended for mastitis. Adequate hydration is essential for overall health and recovery, and there is no benefit to restricting fluids in this context.
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
Explanation
Choice A rationale
Repositioning the newborn every 2 hours during phototherapy is important to ensure even exposure to the light and to prevent skin breakdown. This practice helps in the effective reduction of bilirubin levels.
Choice B rationale
Giving the newborn 30 ml of distilled water after each feeding is not recommended. Hydration is typically maintained through breastfeeding or formula feeding, and additional water is not necessary.
Choice C rationale
Monitoring the newborn's blood glucose level every hour is excessive and not standard practice for phototherapy management. Routine blood glucose monitoring is not indicated unless there are specific concerns.
Choice D rationale
Applying a water-based ointment to the newborn's skin every 6 hours is not necessary and could interfere with the effectiveness of phototherapy. The skin should be kept clean and dry for optimal light exposure. .
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