ATI NUR 209 Final Assessment

Correct Answer: The baseline FHR can be obtained during contractions

Why A is correct:

The baseline fetal heart rate (FHR) should not be obtained during contractions, as uterine contractions can temporarily alter the FHR due to changes in fetal oxygenation, blood flow, or pressure. For accurate assessment, the baseline FHR must be measured during a 10-minute period excluding periods of contractions, accelerations, decelerations, or marked variability. The goal is to determine the fetus’s resting heart rate, not a rate influenced by labor activity. Therefore, this statement is not accurate and is the correct answer to the question.

Why Other Options Are Wrong:

The baseline FHR is normal between 110–160 bpm

This statement is correct. The normal range for baseline fetal heart rate in a term fetus is 110 to 160 beats per minute. Rates outside this range may indicate fetal distress, bradycardia, or tachycardia and require further evaluation.

The baseline FHR is assessed over a 10-minute period

This is also accurate. The standard definition of baseline FHR involves a minimum 10-minute window, during which the mean heart rate is determined. This period must be free of transient changes like accelerations and decelerations to capture a true baseline.

 The baseline FHR can be obtained via ultrasound or auscultation

This is a correct statement. The fetal heart rate can be monitored using external Doppler ultrasound or intermittent auscultation with a fetoscope or Doppler device. Internal monitoring via fetal scalp electrode may also be used in certain clinical settings when membranes are ruptured and cervical dilation allows.

Summary:

The correct answer is A. The baseline FHR can be obtained during contractions, because this is not accurate. The baseline FHR should be determined between contractions to ensure an accurate reading unaffected by transient physiological changes. All other options are true statements regarding fetal heart rate monitoring.

Correct Answer:

Apply breast milk to the nipples before each feeding

Start breastfeeding with the nipple that is less sore

Change the infant's position on the nipples

Explanation :

Breastfeeding can cause nipple soreness, especially in the early days postpartum, but certain interventions can help reduce discomfort:

Apply breast milk to the nipples before each feeding: Applying breast milk to the nipples is a natural remedy that can help with soothing and healing sore nipples. Breast milk has antibacterial properties that can help prevent infection, and it also acts as a natural moisturizer for the skin. Applying it before feedings can help reduce irritation.

Start breastfeeding with the nipple that is less sore: Starting with the less sore breast is a good strategy, as it allows the more painful nipple to recover between feedings. This ensures that the mother isn't continuing to aggravate the sore nipple during each feeding.

Change the infant's position on the nipples: Adjusting the infant’s latching position is crucial in preventing further nipple damage. By changing positions, the pressure on the sore nipple can be relieved, helping to prevent additional discomfort and promoting proper latch technique.

Whyother options are Incorrect:

Wear a tight fitting nursing bra with breast pads inside (Incorrect): Wearing a tight-fitting bra can actually increase discomfort. It may put pressure on the breasts and hinder proper milk flow, which can contribute to engorgement and clogged ducts. The best approach is to wear a well-fitted, supportive nursing bra that doesn’t cause constriction or added pressure. Using breast pads is appropriate for absorbing leakage, but a tight bra isn't recommended for comfort.

Apply ice packs to the nipples before each feeding (Incorrect): While cold therapy (such as ice packs) can be helpful for reducing swelling and inflammation in cases of engorgement, it may not be as helpful for nipple soreness directly caused by latch issues or friction. Warm compresses or using breast milk is generally a better option for soothing sore nipples.

Summary:

To reduce nipple soreness during breastfeeding, the nurse should suggest applying breast milk to the nipples (B), starting with the less sore nipple (D), and changing the infant’s position on the nipples (E) to improve latch and prevent further irritation. Wearing a tight-fitting bra (A) and applying ice packs (C) are not ideal solutions for nipple soreness and may cause further discomfort.

Correct Answer:

I play games with my child every day to keep them as independent as possible.

I use utensils with large, padded handles to help my child feed themselves more easily.

Explanation:

I play games with my child every day to keep them as independent as possible. (Correct):

Playing games with a child who has spastic cerebral palsy is important for encouraging motor skills development and promoting independence. It also supports emotional well-being, enhances social skills, and encourages the child to participate in daily activities, which is essential for their development. Engaging in interactive games tailored to the child’s abilities helps build self-confidence and independence.

I use utensils with large, padded handles to help my child feed themselves more easily.(Correct):

For a child with spastic cerebral palsy, assistive devices like utensils with large, padded handles are highly beneficial. These tools help improve grip and control for children who have difficulty with fine motor coordination. They help the child gain more independence during meals, which is crucial for self-care skills development.

Why the Other Options Are Incorrect:

I perform range of motion exercises every 4 hours to help prevent contractures. (Incorrect):

Range of motion (ROM) exercises are indeed important for preventing contractures and improving muscle flexibility. However, the frequency stated here is too high. Generally, ROM exercises for children with cerebral palsy should be done two to three times a day, not every 4 hours, as overdoing them could cause discomfort and muscle fatigue.

 I give my child carbidopa so that they will stop drooling (Incorrect):

Carbidopa is typically used in combination with levodopa for managing Parkinson's disease and dopamine-related motor symptoms, not specifically for drooling in cerebral palsy. The treatment for drooling in children with cerebral palsy may include the use of anticholinergic medications, such as scopolamine, sialogogues, or even botulinum toxin injections for excessive drooling, but carbidopa is not the appropriate treatment.

I limit my child's interactions with peers to avoid overstimulation and frustration. (Incorrect):

While it is important to avoid overstimulation, social interaction is a key part of a child's development. Limiting peer interactions may hinder social skills development and the opportunity to practice appropriate behaviors. Children with cerebral palsy benefit from interacting with peers in a controlled and supportive environment, as it aids in emotional development and can foster friendships and communication skills.

Summary:

Appropriate care for a child with spastic cerebral palsy involves encouraging independence through activities like playing games (A) and using assistive tools like large-handled utensils (C) to aid feeding. ROM exercises should be done with appropriate frequency, carbidopa is not used to treat drooling, and limiting peer interactions may be counterproductive.

Correct Answers:

Handwashing,

Use of barrier protection

Perineal care of genital lesions

Explanation why they are correct:

Handwashing 

Good hand hygiene is essential in preventing the spread of the herpes virus to other parts of the body or to other people. Patients should wash their hands thoroughly after touching lesions or applying topical treatments to reduce the risk of autoinoculation (spreading the virus to eyes or other mucous membranes).

Use of barrier protection 

Using condoms or other barrier methods during sexual activity reduces the risk of transmitting HSV-2 to sexual partners, although it may not eliminate the risk entirely. Patients should also avoid sexual contact during outbreaks, when the virus is most contagious.

Perineal care of genital lesions 

Proper perineal hygiene helps prevent secondary infections and promotes comfort and healing of herpes lesions. Patients should be advised to keep the area clean and dry, wear loose-fitting clothing, and avoid irritating products.

Why other options are incorrect:

Gardasil injection

The Gardasil vaccine protects against human papillomavirus (HPV), not herpes simplex virus (HSV). While it is important for young people to be vaccinated against HPV, it does not treat or prevent HSV-2.

Penicillin 

Penicillin is an antibiotic, which is ineffective against viral infections like HSV-2. Treatment for HSV involves antiviral medications such as acyclovir, valacyclovir, or famciclovir.

Summary:

The correct answers are A, C, and E. These address infection control, prevention of transmission, and care of active lesions. Gardasil and penicillin are not appropriate for managing or treating HSV-2.

Correct Answer:

Maintain low stimulation environment

Swaddle newborn with legs flexed

Administer oral glucose for comfort

Offer the newborn a pacifier

Explanation:

Maintain low stimulation environment :

Newborns who have been exposed to substances like heroin in utero may experience neonatal abstinence syndrome (NAS), which can cause symptoms such as irritability, tremors, and sensitivity to stimuli. A low-stimulation environment (minimal noise, soft lighting, and gentle handling) helps reduce discomfort and calms the newborn. This intervention is appropriate to support the infant's well-being.

 Swaddle newborn with legs flexed:

Swaddling the newborn with the legs flexed is an appropriate intervention for an infant with NAS. This position provides the infant with a sense of comfort and security, as it mimics the fetal position and helps to reduce symptoms such as tremors. Additionally, the flexed position helps to prevent hyperextension of the legs, which is important for infants with NAS, who may have increased muscle tone.

Administer oral glucose for comfort:

Oral glucose may be administered to infants to help alleviate symptoms of NAS. Glucose can provide comfort by helping to regulate the infant's blood sugar levels, especially since infants exposed to heroin may have issues with glucose metabolism or withdrawal symptoms. Oral glucose is a non-invasive intervention that can calm the infant and reduce irritability.

Offer the newborn a pacifier :

Offering a pacifier is an appropriate intervention for a newborn with NAS. Sucking on a pacifier can provide comfort and help to soothe the infant, especially when the infant is experiencing irritability and withdrawal symptoms. This also supports the infant's oral development and provides a non-pharmacological method of comfort

Why other options are incorrect

Feed the infant half strength formula:

There is no indication that feeding the infant half-strength formula is necessary or beneficial for a newborn with NAS due to heroin exposure. In fact, these infants often require adequate nutrition to support growth and development, and they are typically fed full-strength formula or breast milk, unless contraindicated. The focus should be on nutrition and ensuring the infant receives sufficient calories for growth and recovery.

Observe the newborn in a well-lit nursery :

This intervention is not appropriate for a newborn with NAS. Newborns who are withdrawing from heroin need to be in a low-stimulation environment, not a well-lit nursery. Bright lights and noise can exacerbate the infant's irritability and increase withdrawal symptoms. A dimly lit room is more appropriate for these infants.

Summary:

For a newborn whose mother was addicted to heroin during pregnancy, appropriate interventions include creating a low-stimulation environment, swaddling with legs flexed, offering a pacifier, and administering oral glucose for comfort. Feeding half-strength formula and placing the infant in a well-lit nursery are not appropriate and may exacerbate withdrawal symptoms or discomfort.

Correct Answer: Administer parental antibiotics

Explanation

The priority intervention for an antenatal client at 32 weeks' gestation with premature rupture of membranes (PROM) is to administer parental antibiotics. Premature rupture of membranes increases the risk of infection, particularly chorioamnionitis, which can lead to serious complications for both the mother and the baby, including infection and preterm labor. Antibiotics are typically administered to reduce this risk and prevent infection. In preterm pregnancies, preventing infection is crucial because it can accelerate labor or harm the baby.

Why other options are wrong

Provide emotional support: While providing emotional support is important for any patient, it is not the priority in this situation. The immediate concern with PROM is preventing infection and managing risks related to the premature rupture. Emotional support should follow after addressing the more critical clinical needs.

Assess cervical dilation every 2 hours: While monitoring cervical dilation can be important if labor is suspected, the client is not exhibiting signs of labor at the moment. The priority is preventing infection, which is a higher risk at this point than checking for labor progression.

Prepare for delivery: Although preterm delivery may be necessary if complications arise, the priority is to prevent infection and manage the preterm birth risks through antibiotics and observation. Immediate preparation for delivery would not be warranted unless there are signs of labor or other complications.

Summary

For a client with premature rupture of membranes (PROM) at 32 weeks, the priority intervention is administering antibiotics to reduce the risk of infection. This is crucial because infection can lead to further complications such as chorioamnionitis, premature labor, or harm to the baby. Other interventions, such as emotional support or monitoring cervical dilation, are important but should come after addressing the risk of infection.

Correct Answer: Document the findings and continue to monitor the client.

Explanation

A large amount of lochia rubra with a few small clots is generally expected within the first 1 to 2 hours following delivery. Lochia rubra is the initial postpartum vaginal discharge and consists of blood, decidual tissue, and mucus. It is typically bright red and may contain small clots, especially when the client has been lying down and then gets up.

The fundus being firm, midline, and at the level of the umbilicus is a reassuring sign that the uterus is well-contracted, which reduces the risk of excessive bleeding or postpartum hemorrhage. Since the uterus is firm and there are no signs of abnormal bleeding (e.g., saturation of a pad in 15 minutes, large clots larger than a golf ball, boggy fundus, or signs of hypovolemia), the appropriate action is to document the findings and continue to monitor for any changes. No immediate interventions are necessary at this time.

Why other options incorrect:

Notify the provider immediately: Notify the provider immediately is not warranted unless there are signs of abnormal bleeding, uterine atony, or unstable vital signs. The current findings are within normal postpartum expectations.

Increase the frequency of fundal massage: Increase the frequency of fundal massage is unnecessary because the fundus is already firm and well-contracted. Excessive fundal massage can cause uterine irritation or lead to uterine inversion if done improperly or too aggressively.

Encourage the client to empty her bladder.: Encourage the client to empty her bladder is an important nursing intervention if the fundus is deviated from the midline or not firm, which can indicate a full bladder interfering with uterine contraction. However, in this scenario, the fundus is midline and firm, so bladder distention is not the issue.

Summary:

Option C is correct because the assessment findings—lochia rubra with small clots, a firm midline fundus at the umbilicus—are normal for 1 hour postpartum. There are no signs of complications, so the nurse should document and continue regular monitoring. The other options involve unnecessary or inappropriate interventions for this clinical presentation.

Correct Answer: Retinal hemorrhage

Explanation:

Retinal hemorrhage (Correct):

Retinal hemorrhage is a classic sign of abusive head trauma (AHT), also known as shaken baby syndrome. The violent shaking of an infant can cause blood vessels in the eyes to rupture, leading to retinal hemorrhages. This finding, along with other signs of head trauma, should raise concern for abuse.

Why the Other Options are Wrong:

Laceration to forearm:

A laceration to the forearm is typically a trauma injury that may occur due to accidents or falls, but it is not specifically associated with abusive head trauma. Lacerations on the arms are not typically a sign of shaking or head injury.

Large bruises on the body :

Large bruises may be concerning for abuse, but they are not as definitive for abusive head trauma specifically. Bruises on different parts of the body could result from a variety of causes, including accidental falls, but retinal hemorrhage is a more specific and concerning finding for AHT.

Sunken fontanels:

Sunken fontanels typically indicate dehydration and are not associated with abusive head trauma. While dehydration can be concerning for infants, it is not a direct indicator of abuse.

Summary:

Retinal hemorrhage is the key finding that should make the nurse suspect abusive head trauma in a 2-month-old infant. Other options, such as lacerations or sunken fontanels, are not specific indicators of abusive head trauma and may point to other conditions or injuries.

Correct Answer: Newborn is placed in bassinet on the back

Explanation

Placing a newborn on their back to sleep is the most effective and evidence-based action to reduce the risk of sudden infant death syndrome (SIDS). The American Academy of Pediatrics (AAP) strongly recommends that infants be placed on their backs for all sleep times—both naps and nighttime sleep—until they are 1 year old. This position significantly reduces the chance of airway obstruction and the risk of rebreathing exhaled carbon dioxide, which are both contributing factors in SIDS. Supine (back) sleeping has been consistently shown to be the safest sleep position and is a key component of safe sleep guidelines. Teaching parents to always place their baby on their back demonstrates understanding of the most critical SIDS prevention strategy.

Why other options are  incorrect:

Mother removes pacifier from the newborn’s mouth

Removing the pacifier may unintentionally increase the risk of SIDS. In fact, offering a pacifier during sleep is associated with a decreased risk of SIDS. The mechanism is not entirely understood, but it may help maintain airway patency or prevent deep sleep from which the infant cannot easily arouse. If the pacifier falls out during sleep, it does not need to be replaced, but actively removing it goes against current recommendations.

Newborn is placed in bassinet with blanket draped over them

Using loose blankets in a newborn’s sleep space is unsafe and increases the risk of suffocation and SIDS. Loose bedding can cover the baby’s face, impair breathing, or cause overheating—all risk factors for SIDS. Instead of blankets, parents should be educated to use a sleep sack or wearable blanket, which provides warmth without the dangers of loose fabric.

 The newborn is on an every 2-hour feeding schedule

While regular feeding is an essential part of newborn care and supports growth and development, it is not related to SIDS prevention. Being on a structured feeding schedule does not reflect knowledge or application of safe sleep practices. Therefore, it does not indicate that the teaching about SIDS prevention was effective.

Summary:

Option C is the correct answer because placing a newborn on their back to sleep is a well-established, critical practice in preventing SIDS. The other options either involve unsafe sleep practices (removing the pacifier, using a blanket) or are unrelated to SIDS prevention (feeding schedule)