ATI RN Maternal Newborn

The correct answer is b. amount of lochia.

Explanation

After a cesarean birth, the nurse's priority assessment should be the amount of lochia (vaginal discharge), as this is a key indicator of the mother's uterine healing and a potential sign of postpartum complications.  Excessive bleeding, known as postpartum hemorrhage, can occur, and monitoring the amount of lochia helps detect early signs of hemorrhage, which can be life-threatening. The nurse should assess the lochia for color, amount, and odor, as these can provide important clues about the mother's recovery and potential complications.

Why the other options are wrong:

a. parent-child attachment: While parent-child attachment is important and should be assessed throughout the postpartum period, it is not the priority in the immediate post-cesarean period, where the mother's physical health and potential complications take precedence.

c. patency of the IV catheter: Ensuring that the IV catheter remains patent is important for medication and fluid administration, but it is not as urgent as assessing for postpartum hemorrhage. If there is a problem with the IV, it can be addressed after more critical assessments are completed.

d. quality and quantity of urine: Assessing urine output is important to ensure that the bladder is functioning well, especially following anesthesia from a cesarean birth. However, it is secondary to assessing lochia because excessive bleeding poses a more immediate risk to the mother's health.

Summary:

The priority assessment for a nurse caring for a postpartum client following a cesarean birth is the amount of lochia to monitor for signs of postpartum hemorrhage. While the other assessments are important, ensuring that the mother is not experiencing excessive bleeding takes precedence.

The correct answer is B) 20 weeks - delivery.

Intrauterine fetal demise (IUFD) refers to the death of a fetus in utero after 20 weeks gestation but before the onset of labor or delivery. This term is often used for fetal death occurring after the 20-week threshold of gestation, as fetal death before this point is referred to as a miscarriage or spontaneous abortion.

Why the other options are incorrect:

A) Before 20 weeks: Fetal demise before 20 weeks is not categorized as IUFD; it is typically called a miscarriage or spontaneous abortion. IUFD is used to describe death after 20 weeks gestation.

C) After delivery: After delivery, fetal death is referred to as stillbirth if it occurs after birth but before the umbilical cord is cut. However, intrauterine fetal demise specifically refers to death occurring before delivery.

D) Between 10-15 weeks: The term IUFD is used to describe fetal death after 20 weeks, not within the 10-15 week range. Early fetal loss (before 20 weeks) is typically called a miscarriage or spontaneous abortion.

Summary:

Intrauterine fetal demise (IUFD) occurs after 20 weeks of gestation but before delivery. It is distinct from earlier pregnancy losses (miscarriage or spontaneous abortion) and from stillbirth, which occurs after delivery.

Correct Answer: A. You should have your provider refit you for a new diaphragm

Pregnancy, childbirth, or significant weight changes can alter the size and shape of the cervix and vaginal canal, which may make a previously fitted diaphragm ineffective.

Therefore, the client should have their provider refit them for a new diaphragm postpartum.

Why the Other Options Are Incorrect:

B. You should store your diaphragm in sterile water after each use:

This is incorrect because storing the diaphragm in sterile water can damage it. The diaphragm should be washed with mild soap and water, dried thoroughly, and stored in its case.

C. You should use an oil-based vaginal lubricant when inserting your diaphragm:

Oil-based lubricants can weaken the latex of the diaphragm, making it less effective and more prone to tearing. A water-based lubricant should be used instead.

D. You should keep the diaphragm in place for at least 4 hours after intercourse:

This is incorrect because the diaphragm should remain in place for at least 6 hours after intercourse but no more than 24 hours to reduce the risk of infections like toxic shock syndrome.

Key Points:

Postpartum changes necessitate refitting for the diaphragm.

Proper care and use are critical for diaphragm effectiveness.

Water-based lubricants should be used, and the diaphragm must remain in place for at least 6 hours after intercourse.

Correct Answer A: Place the client in a lateral position.

Explanation

Late decelerations on a nonstress test indicate a deceleration of the fetal heart rate that begins after the contraction has started and returns to baseline after the contraction ends. This pattern is often indicative of uteroplacental insufficiency, which can result in reduced oxygenation to the fetus. The first intervention in this case should be to place the client in a lateral position, as this can help increase uterine blood flow and improve placental perfusion by relieving pressure on the inferior vena cava. This position allows better circulation and can alleviate the cause of the late decelerations.

Why other options are wromg

Why B is incorrect Administer lactated Ringer's via IV bolus

Administering an IV bolus (e.g., lactated Ringer's) is a common intervention to help increase circulating volume and improve perfusion, but it is not the first intervention. The first step in managing late decelerations should be positioning the client to improve blood flow to the placenta. If the lateral position does not resolve the decelerations, an IV bolus can be considered next, especially if there are signs of hypovolemia.

Why C is incorrect Prepare the client for a cesarean birth

While late decelerations may require closer monitoring and could ultimately lead to a decision for cesarean birth (especially if they persist or worsen), this is not the first intervention. Immediate actions should focus on improving fetal oxygenation through position changes and other supportive measures. A cesarean birth should only be considered if the fetal distress persists despite interventions.

Why D is incorrect Elevate the client's legs

Elevating the client’s legs is often recommended for hypotension, but it is not typically effective for improving uteroplacental perfusion. The first step to address late decelerations is positioning the client laterally to optimize placental blood flow. Elevating the legs would not address the underlying cause of the decelerations as effectively as lateral positioning.

Summary:

The first and most appropriate intervention for managing late decelerations in a nonstress test is to place the client in a lateral position. This helps improve placental perfusion, which can alleviate the decelerations. If the late decelerations persist, other interventions like IV bolus or preparation for cesarean birth may be needed, but positioning is the initial step in improving fetal well-being.

The correct answer is B) Nitrazine paper test.

Explanation

The Nitrazine paper test is used to assess whether the membranes have ruptured. Amniotic fluid has a higher pH (usually around 7.0-7.5), which turns Nitrazine paper blue, indicating that the amniotic sac has ruptured. This test helps differentiate amniotic fluid from urine or vaginal secretions, which typically have a lower pH.

Why the other options are incorrect:

A) NST (Non-stress test): The NST is used to assess fetal well-being by measuring the fetal heart rate and its response to fetal movements. It does not verify the rupture of membranes.

C) Routine Urinalysis: A routine urinalysis checks for various substances in the urine, such as protein, glucose, and ketones, but it does not help in verifying the rupture of membranes. Amniotic fluid and urine are different, and a urinalysis is not designed to differentiate between them.

D) Glucola Screening test: The Glucola Screening test is a test used to screen for gestational diabetes by measuring the blood glucose level after the mother drinks a glucose solution. It does not assess or verify the rupture of membranes.

Summary:

To verify the rupture of membranes, the Nitrazine paper test is commonly performed as it detects the higher pH of amniotic fluid. Other tests like NST, routine urinalysis, and Glucola screening are unrelated to the diagnosis of membrane rupture.

Correct Completion : muscle tone

The nurse should further evaluate Respiratory characteristics, muscle tone, and cry characteristics to determine if the newborn is experiencing a complication.

Rationale:

Respiratory characteristics: At 1830, the newborn's respiratory rate increased to 72/min, which is above the normal range for a newborn (30–60 breaths per minute). Additionally, the respirations are described as shallow and irregular, which may indicate respiratory distress or a sign of neonatal abstinence syndrome (NAS).

Muscle tone: At 1830, the nurse notes increased muscle tone with tremors upon stimulation, which is a key sign of withdrawal in neonates exposed to opioids in utero. Hypertonia and jitteriness warrant further evaluation.

Cry characteristics: The newborn is described as having a high-pitched cry, which is a common sign of neurologic irritability or withdrawal. This type of cry is distinct from the typical newborn cry and should prompt further assessment.

Why the other options are incorrect:

Babinski reflex: A positive Babinski reflex is normal in newborns up to 12 months of age and does not indicate a complication in this context.

Moro reflex: An exaggerated Moro reflex may be seen in withdrawal, but this reflex alone is not as specific or concerning as the overall tone, cry, and respiratory status. Moro can vary with stimulation and other factors.

Heart rate: While the heart rate increased from 144/min to 158/min, both values are still within the normal newborn range (120–160/min) and do not necessarily indicate a complication on their own.

Summary:

The newborn is showing signs suggestive of neonatal abstinence syndrome (NAS) due to in utero opioid exposure. The nurse should focus further evaluation on Respiratory characteristics, muscle tone, and cry characteristics, as these findings may indicate neurologic and systemic complications related to withdrawal.

Correct Answers:

A. Flushing

D. Depressed respirations

E. Extreme muscle weakness

Explanation

Magnesium sulfate is commonly used in preterm labor to prevent contractions and manage preeclampsia. However, it carries certain risks and adverse effects, especially when administered intravenously.

A. Flushing

Flushing is a common side effect of magnesium sulfate, particularly with rapid infusion. It occurs due to the vasodilation effects of the medication, which can cause warmth, redness, and skin flushing.

D. Depressed respirations

Depressed respirations are a serious adverse effect of magnesium sulfate, particularly when the levels become toxic. Magnesium sulfate acts as a CNS depressant, and elevated levels can lead to respiratory depression, requiring careful monitoring of the client's respiratory rate and depth.

E. Extreme muscle weakness

Extreme muscle weakness is another adverse effect of magnesium sulfate, especially at high levels. Magnesium has a relaxing effect on smooth and skeletal muscles, and high doses can cause muscle weakness, including difficulty in moving or controlling muscles.

Explanation of Incorrect Options:

B. Hypertension

Magnesium sulfate is generally used to lower blood pressure, especially in the case of pre-eclampsia or eclampsia, so hypertension is not an expected side effect. It is actually used to manage elevated blood pressure in certain conditions.

C. Increased urinary output

Magnesium sulfate does not generally cause increased urinary output. In fact, it can sometimes lead to decreased urinary output or oliguria, especially in cases of toxicity. The medication is excreted through the kidneys, so renal function and urinary output should be monitored.

F. Hyperactive deep tendon reflexes

Hyperactive deep tendon reflexes are more commonly seen in conditions of magnesium deficiency, not magnesium excess. In fact, hyporeflexia (decreased reflexes) is a sign of magnesium toxicity, so hyperactive reflexes are unlikely to occur.

Summary:

Flushing, depressed respirations, and extreme muscle weakness are common adverse effects of magnesium sulfate, particularly when toxicity occurs. Hypertension is not a typical effect of magnesium sulfate. Increased urinary output and hyperactive deep tendon reflexes are not related to magnesium sulfate use, as they are more commonly associated with conditions like renal dysfunction or magnesium deficiency.

Answer: A) Placenta praevia

Explanation

A) Placenta praevia: This is a contraindication for induction of labor because the placenta is abnormally positioned over or near the cervix, which could cause severe bleeding during induction and delivery. Vaginal delivery is typically avoided, and cesarean section is often recommended.

Why Other Options are Incorrect

B) Mild maternal hypertension: Mild hypertension is not an absolute contraindication for induction of labor. In some cases, induction may be considered to prevent complications, but it would depend on other factors such as gestational age and fetal well-being

C) Low-risk pregnancy: A low-risk pregnancy is not a contraindication for induction. In fact, women with low-risk pregnancies who meet other criteria may be candidates for induction when necessary

D) Healthy HIV-positive women with undetectable viral load: HIV-positive women on anti-retroviral therapy with an undetectable viral load are generally not contraindicated for induction. The viral load must be monitored, but undetectable viral loads reduce the risk of transmission and typically allow for vaginal delivery.

Summary:

Placenta praevia is a clear contraindication for labor induction due to the increased risk of bleeding. The other options, including mild hypertension, low-risk pregnancies, and healthy HIV-positive women with undetectable viral loads, are not absolute contraindications for induction.

Correct Answer: Administer 500 mL lactated Ringer's IV bolus.

Explanation

A steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth may indicate postpartum hemorrhage. Postpartum hemorrhage can occur from multiple causes, including uterine atony, lacerations, hematomas, or retained placenta. Given that fundal massage alone has not resolved the bleeding, the client may be at risk for hypovolemic shock, so administering a 500 mL lactated Ringer's IV bolus is the priority intervention. The IV bolus helps to restore blood volume and maintain hemodynamic stability, which is essential in managing hemorrhage and preventing shock.

Why the Other Options Are Incorrect:

Apply an ice pack to the incision site: While ice may provide comfort and help reduce swelling, it will not address the underlying cause of the bleeding, which may be due to uterine atony or hemorrhage from another source.

Replace the surgical dressing: Replacing the dressing is part of the general care but does not directly address the cause of the ongoing bleeding. The nurse needs to focus on stabilizing the patient and managing the hemorrhage.

Evaluate urinary output: While evaluating urinary output is important in assessing for bladder injury or retention, fluid resuscitation is the immediate priority to address potential hypovolemic shock from hemorrhage. Once the client's hemodynamic status is stabilized, further investigation for other causes of bleeding (like bladder injury) can follow.

Summary:

The nurse should administer an IV bolus of lactated Ringer's to restore fluid volume and stabilize the patient who is experiencing postpartum hemorrhage, ensuring that the client’s circulation and hemodynamic status are supported while further assessment and interventions are planned.