ATI RN Maternal Newborn

The correct answer is: D. Contraction frequency every 90 seconds with a duration of 80 seconds

Explanation

Oxytocin is used to induce or augment labor by stimulating uterine contractions. However, the infusion must be carefully monitored to avoid uterine hyperstimulation, which can be harmful to both the mother and the fetus. Contraction frequency every 90 seconds with a duration of 80 seconds: This scenario indicates uterine hyperstimulation. The contractions are too frequent (every 90 seconds) and too long in duration (80 seconds), which can lead to uterine tetany (sustained contractions) and insufficient oxygenation for the fetus.  This situation requires the immediate discontinuation of oxytocin to prevent fetal distress, uterine rupture, or other complications.

Explanation of Other Options:

A. Blood pressure of 137/88: This blood pressure reading is within the normal range for pregnancy (although still lower than 140/90, which would be considered prehypertension). There is no immediate need to discontinue oxytocin for this blood pressure.

B. Soft abdomen between contractions: A soft abdomen between contractions is a normal finding and does not indicate a need to discontinue oxytocin. A firm abdomen might indicate uterine hyperstimulation or uterine tone, but a soft abdomen between contractions is typical.

C. Early decelerations detected: Early decelerations are usually a normal finding during labor and are typically caused by fetal head compression during contractions. They are not an indication to discontinue oxytocin unless they are accompanied by other signs of fetal distress (e.g., late decelerations or prolonged decelerations).

Summary:

Oxytocin should be discontinued if uterine hyperstimulation is noted, as indicated by contractions occurring too frequently or with too much duration, as seen in option D. This is critical to prevent maternal and fetal complications.

The correct answer is D. I should empty my bladder before the procedure.

Explanation

Amniocentesis is a procedure used to collect amniotic fluid to test for genetic disorders, lung maturity, and other conditions. Understanding the procedure and preparation is crucial for the client.

D. I should empty my bladder before the procedure:

This statement is correct. It is important for the client to empty their bladder before the procedure. A full bladder can provide a better view of the uterus and amniotic sac through ultrasound, but an empty bladder reduces the risk of puncturing the bladder during the procedure. It also helps the client feel more comfortable during the process.

Why Other Options are Incorrect

A. I should start fasting 24 hr before the procedure:

This statement is incorrect. Fasting is not required for an amniocentesis. Unlike some other procedures, amniocentesis does not require the client to fast before the procedure.

B. I will be asleep during the procedure:

This statement is incorrect. An amniocentesis is usually performed with the client awake. Local anesthesia may be used to numb the area, but the client is generally awake during the procedure. The procedure is minimally invasive, and general anesthesia is not typically used.

C. I will be lying on my side during the procedure:

This statement is incorrect. The client is typically positioned lying on their back for the procedure with a slight tilt (usually to the left side) to avoid compression of the vena cava, not lying entirely on their side. The position helps with access to the abdomen for the needle insertion.

Summary:

I should empty my bladder before the procedure is the correct answer, as it aligns with standard guidelines for amniocentesis preparation.

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.

Answer:D) Improved mental health

Explanation

D) Improved mental health is incorrect. Obesity during pregnancy is associated with poorer mental health outcomes, such as depression, not improved mental health.

Why Other Options are Incorrect

A) Gestational diabetes is a common risk associated with obesity during pregnancy. Women with a BMI ≥30 should be offered a glucose tolerance test between 24–28 weeks to screen for gestational diabetes.

B) Neural tube defects are also a risk associated with obesity. It is recommended that all women, especially those with obesity, take 5 mg of folic acid daily to reduce the risk of neural tube defects.

C) Increased length of hospital stay is a known risk associated with obesity in pregnancy due to complications that may arise, requiring longer hospital admissions and care.

Summary:

Obesity during pregnancy increases the risk of various maternal, fetal, and maternity service complications. These include gestational diabetes, neural tube defects, macrosomia, prolonged hospital stays, and poor mental health. Therefore, "Improved mental health" is not a risk and is the correct answer to the question.​​​​​​​

Correct Answer A: Assess for edema.

 

In a client with preeclampsia without severe features, it is important to monitor for signs of worsening preeclampsia, including edema.

Postpartum edema can indicate fluid retention and possible complications like worsening hypertension or preeclampsia. Therefore, regular assessment of edema is an appropriate action. 

Why the Other Options Are Incorrect:

Restrict daily oral fluid intake.

 There is no indication that fluid intake should be restricted in a client with preeclampsia without severe features. In fact, restricting fluids may lead to dehydration and is not typically recommended unless there is another specific concern (e.g., kidney dysfunction). 

Obtain a prescription for misoprostol.

Misoprostol is used to manage postpartum hemorrhage by stimulating uterine contractions, but it is not indicated for clients with preeclampsia without severe features unless there is excessive bleeding or uterine atony. There is no evidence to suggest that this client needs misoprostol for hemorrhage management.

Administer an IV bolus of lactated Ringer's.

An IV bolus of lactated Ringer's is typically used in cases of hypovolemia or dehydration. However, in preeclampsia without severe features, there is no indication for an IV bolus unless the client is showing signs of shock or hypovolemia. Fluid administration should be carefully monitored in preeclampsia to avoid exacerbating edema and hypertension.

Summary:

The nurse should assess for edema in a postpartum client with preeclampsia without severe features to monitor for potential worsening of the condition. The other options, including restricting fluid intake, administering misoprostol, and giving an IV bolus, are not appropriate in this case unless there are other indications.

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.

The question asks which of the images represents the *first step of Leopold maneuvers*. 

Leopold maneuvers are a series of four steps used to determine the fetal position, presentation, and engagement in the uterus:

1. First maneuver: The nurse palpates the fundus of the uterus to determine which fetal part (head or buttocks) occupies the upper part of the uterus.  

2. Second maneuver: The nurse palpates the sides of the uterus to locate the fetal back and small parts.  

3. Third maneuver: The nurse palpates above the symphysis pubis to confirm fetal engagement and identify the part of the fetus in the pelvis.  

4. Fourth maneuver: The nurse uses both hands to determine the fetal position and descent by feeling the cephalic prominence.  

From the image, the "First maneuver" (top-left image) is the correct step, as the hands are placed on the top of the abdomen (fundus) to assess the fetal part there. Therefore, the correct answer is:

a. Hands on either side of the baby's head.

The correct answers are:

A. Lanugo

C. Weak grasp reflex

D. Translucent skin

Explanation

A. Lanugo: Lanugo is the fine, soft hair that covers the body of a premature newborn. It is common in babies born before 32 weeks of gestation. At 32 weeks, the newborn is likely to have lanugo, especially on the shoulders, back, and forehead.

C. Weak grasp reflex: Premature infants, especially those born at 32 weeks, typically exhibit a weak grasp reflex because the nervous system is not fully developed. The grasp reflex becomes stronger as the infant matures closer to full term.

D. Translucent skin: Premature infants often have translucent skin, which is thin and may show blood vessels clearly underneath. This is due to the lack of subcutaneous fat and skin development that typically occurs in the later stages of pregnancy.

Why the other options are incorrect:

B. Long nails: Long nails are not typically seen in premature infants. Preterm babies generally have short nails because their fingernails develop fully closer to full-term gestation (around 40 weeks).

Summary:

For a newborn born at 32 weeks of gestation, lanugo, a weak grasp reflex, and translucent skin are expected findings due to the baby’s level of development at this stage.

Correct Answer: D All of the above

Explanation

Signs of troubled breathing in a newborn can include a variety of physical cues that indicate respiratory distress or difficulty. These signs include:

A. Nasal Flaring: Nasal flaring is a sign of increased effort to breathe and is often seen when a newborn is trying to take in more oxygen. It occurs as the infant's nostrils open wider to allow for more airflow.

B. Chest Retractions: Retractions occur when the skin between the ribs or below the rib cage pulls in with each breath. This suggests the baby is struggling to breathe, as the muscles around the chest are being used more than normal to help draw air into the lungs.

C. Generalized Cyanosis: Cyanosis refers to a bluish or purplish color of the skin, lips, or tongue, which indicates insufficient oxygen levels in the blood. If the cyanosis is generalized (not just around the mouth), it suggests significant respiratory distress and requires immediate attention.

Summary:

All of the options listed nasal flaring, chest retractions, generalized cyanosis, abnormal breath sounds, and grunting on exhalation are signs of troubled breathing in a newborn. These signs indicate that the newborn is experiencing difficulty in maintaining adequate respiratory function and should be promptly evaluated and managed by healthcare providers. Therefore, the correct answer is D. All of the above.