ATI RN Maternal Newborn 2023 at Baton Rouge Community College

Explanation

The prescribed dose is 250 mg, and the available tablet strength is 500 mg. To calculate the number of tablets needed, divide the prescribed dose by the available dose: 250 mg ÷ 500 mg = 0.5 tablet. This means the nurse should administer half of a tablet per dose. Rounded to the nearest tenth, the correct amount remains 0.5 tablet.

Correct Answer Is:

B. 0.5 tablet.

Explanation

Uterine atony is the most common cause of postpartum hemorrhage and occurs when the uterus fails to contract effectively after delivery. A firm, contracted uterus compresses blood vessels at the placental site and limits bleeding. The nurse’s priority intervention is to perform a fundal massage to stimulate uterine contractions and promote uterine firmness. Prompt fundal massage can significantly reduce bleeding and prevent progression to severe hemorrhage.

Correct Answer Is:

B. Perform a fundal massage.

Explanation

B. Hypotonia
Hypotonia is a common sign of neonatal hypoglycemia and reflects inadequate glucose supply to the central nervous system. Low blood glucose levels impair neuromuscular function, leading to decreased muscle tone, lethargy, and poor feeding. This finding is concerning in the early newborn period and warrants prompt blood glucose evaluation and intervention.

C. Jitteriness
Jitteriness is a classic and early manifestation of neonatal hypoglycemia. It occurs due to increased neuromuscular excitability caused by insufficient glucose available to the brain. Unlike seizures, jitteriness typically stops when the affected limb is held. Persistent jitteriness in a newborn should prompt immediate assessment of blood glucose levels.

D. Temperature instability
Newborns rely heavily on glucose for thermoregulation. Hypoglycemia can impair the newborn’s ability to maintain body temperature, resulting in temperature instability, including hypothermia. This finding is especially significant in the first hours after birth and may be one of the earliest signs of low blood glucose requiring prompt evaluation and treatment.

Correct Answer Is:

B. Hypotonia
C. Jitteriness
D. Temperature instability.

Explanation

The client is experiencing uterine tachysystole (more than five contractions in 10 minutes) with a non-reassuring FHR, indicating fetal compromise. The priority intervention is to immediately discontinue oxytocin, as it is the causative agent stimulating excessive uterine activity. Stopping the infusion reduces uterine contractions and improves uteroplacental perfusion. Other interventions, such as repositioning, oxygen administration, or tocolytics, may follow if fetal status does not improve after oxytocin is stopped.

Correct Answer Is:

D. Discontinue the oxytocin IV infusion.

Explanation

Pouring warm water over the perineum helps stimulate the micturition reflex and relaxes the perineal muscles, making it easier for the client to void. During labor, bladder distention can interfere with fetal descent and increase discomfort, so facilitating urination is important. This noninvasive intervention is commonly effective and promotes bladder emptying without altering labor progression.

Correct Answer Is:

C. Use a squeeze bottle to pour warm water over the client's perineum.

Explanation

Newborn car seats should be installed at approximately a 45-degree angle to keep the infant’s airway open and reduce the risk of airway obstruction. This angle helps prevent the newborn’s head from falling forward, which could compromise breathing. Proper positioning is essential for safety during travel, especially in infants with limited head and neck control.

Correct Answer Is:

D. “The car seat should be positioned in the car at a 45-degree angle.”

Explanation

Epidural opioids can cause delayed respiratory depression, which may occur several hours after administration and can be life-threatening if not promptly identified. For the first 24 hours following a cesarean birth, the nurse’s highest priority is closely monitoring respiratory rate, depth, and oxygen saturation. Early detection of hypoventilation allows for rapid intervention and prevents serious complications such as hypoxia, making respiratory assessment the top priority over pain, cardiac status, or urinary output.

Correct Answer Is:

B. Respiratory status.

Explanation

A. Exaggerated Moro reflex
Newborns with neonatal abstinence syndrome commonly exhibit neurologic hyperexcitability due to withdrawal from substances such as opioids. This hyperexcitability results in exaggerated reflexes, including an exaggerated Moro reflex. The infant may startle easily and display excessive motor responses to minimal stimulation.

C. Tachypnea
Tachypnea is a frequent finding in neonatal abstinence syndrome and reflects autonomic nervous system dysregulation. Withdrawal increases metabolic demands and sympathetic nervous system activity, leading to rapid breathing. Persistent tachypnea can also contribute to feeding difficulties and increased caloric expenditure.

D. Shrill pitched cry
A high-pitched, shrill cry is a classic and hallmark sign of neonatal abstinence syndrome. It occurs due to central nervous system irritability and heightened sensitivity to environmental stimuli. This type of cry is often persistent, difficult to console, and serves as an important clinical indicator of withdrawal severity.

Correct Answer Is:

A. Exaggerated Moro reflex
C. Tachypnea
D. Shrill pitched cry.

Explanation

Terbutaline is a beta-adrenergic agonist used as a tocolytic to suppress uterine contractions. Because it stimulates beta-1 and beta-2 receptors, common adverse effects include tachycardia, heart palpitations, tremors, nervousness, and hyperglycemia. Palpitations occur due to increased heart rate and myocardial stimulation and should be closely monitored, as excessive cardiovascular effects may require discontinuation of the medication.

Correct Answer Is:

D. Heart palpitations.