ATI RN Maternal Newborn Proctored Exam Version 4 With Answers (33 Solved Questions)

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MATERNAL NEWBORN ATI EXAM STUDY GUIDEVERSION 4●Amniocentesis is a prenatal test. Is the sampling of amniotic fluid using a hollow needleinserted into the uterus, to screen for developmental abnormalities in a fetus.●Prescribed for a pt. who is at increased risk of having a baby with a birth defect orgeneticcondition.●An ultrasound transducer is used to show a baby's position in the uterus on a monitorprior to procedure.●It may be performedafter14 weeks of gestation.Patient Education●Instruct client toempty her bladderprior to procedure●During procedureslight pressure will be felt, keep breathing.○The diaphragm is lowered when pt holds the breath.Nursing Interventions●With Rh negative will be given Rho(D) immune globulin, to protect against Rhisoimmunization.●Monitor FHR after the procedure for30mins●Notify provider for leakage, bleeding on site, pressure, contractionULTRASOUND EDUCATION: () page 29

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●instruct patient to havefull bladder.“Drink 1 quart of waterprior to the procedure●put the Wedge UNDER the right buttuck to prevent supine hypotention.NONSTRESS TEST: NURSING INTERVENTIONS: page 31●“What are you looking at while you monitor my baby?”○“This test monitors the response of your baby’s FHR to fetal movement.”●Which trimester can this noninvasive test be performed? 3rd, 32 weeks●Let's look at 2 strips to determine reactive vs. non reactive.○Let’s go over the reactive definition AGAIN!○Nonreactive, baby is sleeping, Opioid and nicotine(smoking) can cause baby torelax which can cause a false nonreactive NST●Why do we ALSO need to connect the client to the Toco transducer during this test?○If an acceleration occurs at the same time as a contraction it does not count●Best Maternal Position during this exam?○High fowler’s orleft side○Supine with wedge under hip●What is the ‘normal’ range for the FHR? (page 86)○110-160 bpm○After birth: 100-160 bpmNONSTRESS TEST: RESULTS:)-third trimesterDone twice a week at 28-32 weeks gestation, IF HIGH RISK PREGNANCY (PAGE 31,BOTTOM LEFT under Client Presentation.)●Reactive (good): FHR normal baseline with moderate variability. Accelerates at least 15beats for 15 sec and it occurs twice during 20 mins●Remember, it’s not counted as an acceleration IF it occurs DURING a contraction!!!●Non-reactive: no demonstration of 2 qualifying accelerations in 20 mins●Some medications, like Opioids & Nicotine can cause non-reactive results.○Stimulate baby for 3 sec, give food ordrink OJ○Reffered to get BPP or CST●False non-reactive NST whenbaby is asleep (sleep periods 20-30 mins), if Pt is onopioids (dilaudid) or is a smoker (page 31)●Moderate variability with a minimum of2 accelerations●What is the definition of a acceleration?○15 bpm above the fetal baseline and lasts for 15 secondsduring a 20 minuteperiod. (I say, “it’s a 15 by 15”)

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○Less than 32 weeks = 10 bpm, lasts 10 secondsIdentification of Prolonged Decelerations:●Decrease in FHR is 15 beats/min or more BELOW THE BASELINE and lasts forat least2 min but less than 10 if sustained for10 min its a baseline change.Nursing interventions for Prolonged Decelerations: )●Notify provider●Stay with patient’●Reposition pt. (Turn on side)--always least invasive action first!!!●MaternalOxygen--facemask at 8-10L/min●IV fluid bolusAssessing Fetal Lung maturity (prior to birth):)--PAGE 34●Preterm baby lungs are not mature no surfactant.●Amnio for L/S RATIO AND PG presence.--page 34○L/S Ratio-2:1 ratio indicates fetal lung maturity (2.5:1 or 3:1 for a client withdiabetes) Its ration should be higher than standard.○Absence of PG (phosphatidylglycerol) = respiratory distress :WANT PG forlung maturity○Obtained via amniocentesis●Mom at risk of preterm deliverywill receive 2 doses of betamethasone (corticosteroid)○Enhance fetal lung maturity○Doses 24 hrs apart○Prolong labor so you can to give both dosesExpected Lab findings:●BUN○First trimester: 7-12mg/dL○Second trimester: 3-13 mg/dL○Third trimester: 3-11 mg/dL●Hematocrit: 30-40 %●Hemoglobin: 11-15 g/dL●Platelets: 150,000-400,000●Liver enzymes (ALT 8-20 and AST 5-40)

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●Protein is NEVER normal in urineDescribe fetal Late deceleration:★Fetal heart rate slowsaftercontraction has started and returns to baseline wellaftercontraction has ended.Causes of late decel.●Uteroplacental insufficiency causing inadequate fetal oxygenation.Interventions●Side lying positionfirst action●Increase rate of IV fluid●Discontinue oxytocin●Administer oxygen 8-10 L via nonrebreather face mask●Elevate legs●Prepare for assisted vaginal birth or cesareanPitocin (Oxytocin)●No more than 5 contractions in 10 minutes●No more than 7 contractions in 15 minutes●Contraction longer than 90 seconds is hyper-contraction and leads to fetal distress○D/c or lower the dose○A prolonged contraction duration(greater than 90 seconds) or too frequentcontractions (more than five in a 10-min period) without sufficient time foruterinerelaxation (less than 30 seconds)in between can reduce blood flow tothe placenta. This can result in fetal hypoxia and decreased FHRGBBS: patient education regarding screening:●screen at 35 weeks to 37 weeks, and if it has positive, antibiotic treatment willbe givenduring labor/after SROMHOW DO YOU EXPLAIN THIS TO YOUR CLIENT

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●Natural bacteria, sometimes leaks out and baby can be exposed during vaginal birth.○Can cause neurological issues (cerebral palsy)○Give antibiotic q4hrs IV while in labor; stopantibiotics once baby is born.○Client does NOT need antibiotics if she’s going to have a c-section.Teach client about hysterosalpingography:●outpatient radiological procedure in which dye is used to assess the patency of fallopiantubes for imaging.●Assess for history of iodine and seafood allergies prior to procedure (because of thecontrast dye)●If allergic to shellfish and needs procedure done, pt will premedicated withDiphenhydramine(Benadryl)Evaluating lab values for a client with Preeclampsia:pg 60UA= protein 1-2 is mild, +3 is chronicAt risk for HELLPHemolysis: results in anemia and jaundiceElevatedLiver enzymesLowPlatelets : less than 100,000 results in bleedingLabs:1.albumin : 3.5-52.Ammonia: 15-453.bilirubin : 0.1-1,04.protein :0.85.Elevated ALT and AST (liver enzymes6.CBC-platelets 150,000-400,000under 100,000Hyperemesis Gravidarum:●Signs and symptoms○Excessive vomiting, nausea, increased pulse, decreased BP

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○Results in5%weight loss, electrolyte imbalances, acetonuria, ketosis●Nursing Interventions○Monitor I&O.○Assess skin turgor and mucous membranes.○Monitor vital signs.○Monitor weight.○Monitor lab for ketone and acetone in urinalysis, electrolytes andhemoconcentrationin CBC○Administer IV LR, supplements, antiemetics as ordered○Advance the diet as tolerated●Education○Small frequent meals○Fluids between meals○Crackers at bedside in the morning○Encourage gatorade○Notify Provider■Can’t hold anything down for 12 hrs (@ riskfor dehydration-uterus tocontract)Expected vital sign changes during pregnancy:●1st trimester: B/P measurements arewithin the prepregnancy range●Systolic slight or no increase from pre pregnancy levels●Diastolic: slight decreases around 24-32weeks●Will gradually return to prepregnancy level by the end of pregnancyPulse●Increases 10-15/min around 32 weeks of gestation and remain elevated throughout theremainder of the pregnancyRespirations●Unchanged or slightly increased●Shortness of breathmay occur due to expanding uterusCircumcision site care:client education●Apply gauze lightly to penis if there’s bleeding,water-based lubricant●Fan fold diapers to prevent pressure on area●Change diapers at least every 4 hours and clean penis with warmwater each change●Avoid tub baths until healed; trickle warm water on penis(DO NOT WIPE)●Film of yellowish mucus may appear-do not wash it off

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●Avoid pre moistened towelettes to clean the penis becauseit may contain alcohol●Clamp procedure: applypetroleum jelly each diaper change for at least 24 hours aftercircumcisionPlastibell circumcision: client education●Provider will tie a suture tightly around the foreskin & with pressure the excess foreskinis removed. ~5-7 days the plastibell drops offleaving clean circumcision.●NO bottle feeding for 2-3 hours prior to procedure to prevent vomiting/aspiration. (Thosewho are breastfed can nurse up until the procedure)●AVOID alcohol towelettes.●DO NOT use petroleum jelly.●DO NOT give tub bathuntil circumcision is healed.●Change diaper ~4 hours & clean with WARM water.●Notify of S/S of infection. A film of yellow mucus can form over glans (it is part of thehealing process)●Give acetaminophen as prescribed●EDUCATE MOM TO CALL PROVIDER○Colorof penis changes reddish, bluish○Excess amount of bleeding○If plastibell falls off before 5 days○Unresolvable pain (grimacing and excessive crying)○Any discharge, swelling, strong odor, tenderness,○decrease in urination,○Fever 100.4 F (38 C) and aboveYour c-section client begins to hemorrhage when you arrive in the recovery room, describethe top 3 nursing actions and why those are the top 3:(L1.Call provider2.Firm massage fundus, monitor v/s, assess for source of bleeding.3.Assess fundus height , firmness and psn. If uterus is boggy, massage fundus to increasemuscle contraction.4.Assess lochia and other clinical findings of bleeding such as lacerations, episiotomy orhematoma.5.Maintain or initiate isotonic fluids, ( LR or 0.9 Sodium Chloride) Colloid volumeexpanders such as albumin and blood products (packed RBC’s and fresh, frozen plasma)6.Provide O2, 2-3 L min per nasal cannula and monitor O2 sat. Elevate pt legs 20-30degrees to promote venous return.VS changes: HR increased, BP decreased, Urinary output decrease, SPO2 decreased

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Priority nursing assessment (top 3) after Epidural placement:1.Maternal VS’s: B/P-at risk for B/P to drop and HR (fyi: nausea = Low BP)2.FHR3.Pain-was epidural successful ?4.Temp at risk for infection (CLE & Foley)-maternal fever 100.4 F5.FALL RISKSpecific labs drawn during prenatal care and : ): (Rubella, ABO, RH factor, etc.)●During prenatal care, Obtain initial laboratory tests, including hemoglobin, hematocrit,WBC, blood type and Rh (rhogam) , rubella titer, urinalysis(protein, ketones, WBC) renalfunction test, Pap test, cervical cultures, HIV antibody, hepatitis B surface antigen,toxoplasmosis, andRPR (syphilis) or VDRL.●Rh-negative and not sensitized, the indirect Coombs’ test is repeated between 24 and 28weeks of gestation●Group B Streptococcus (GBS): Obtain a vaginal/anal culture at 35 to 37 weeks ofgestation to assess for GBS infection.●One-hour glucose tolerance (oral ingestion or IV administration of concentrated glucosewith venous sample taken 1 hr later [fasting not necessary]): Identifies hyperglycemia;done at initial visit for at-risk clients and at 24 to 28 weeks of gestation for all pregnantwomen (greater than 140 mg/dL requires follow up).Glucose Testing: prenatal (Crystal)●1hr initial visit○24-28 wks gestationfasting is not necessary○50 grams oral glucose loaded, followed by plasma glucose analysis 1 hour later○Positive glucose screening is 130-140 or greater additional testing with a 3 houroral glucose tolerance test is indicatedOral glucose tolerance test (3 hour);●Following overnight fasting , no caffeine, and abstinence of smoking for 12 hr prior totesting; afasting glucose is obtained, a 100 g glucose load is given and serum glucoselevels are determined at 1,2,3 hr following glucose ingestion○Total of 4 blood draws (fasting and one every hr for 3 hrs)

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○Two elevations are required to be diagnosed with gestational diabetesPrenatal Screening: client education:(Nitza)Done w/in the first 12 weeks. Determine estimated due date. Obtain medical and nursing historyto include social supports. Perform physical assessment to include pt baseline weight, v/s andpelvic exam.LABS-Blood type, RH factor, and presence of irregular antibodies.●Indirect Coombs to identify pt sensitized to RH + blood.●CBC to detect anemia,●Hgb electrophoresis ( identifies sickle cell and thalassemia) Rubella titer, Hep B,●Urinalysis to check pregnancy, HCG, DM, HTN, renal disease, infection. Pap test andvag/cervical culture.●PPD (tuberculosis screen)●VDLR ( test for syphilis, HIV, screen for TORCH, and Maternal Serum alpha-fetoprotein(MSAFP)What is abstinence Syndrome(drug withdrawal)? Assessment of a newborn with this issue.Nursing interventions/management:(Jaleya)★Withdraw from physically dependent substance use; mother use during pregnancy orbefore knowingAssessment:●Opiate withdrawal: Abstinence scoring●Heroin withdrawal: low birth weight, SGA, increased risk of SIDS, abstinence syndrome●Methadone withdrawal: Abstinence syndrome, increased incidence of seizures, sleeppattern disturbances, higher birth weight thanheroin use●Marijuana withdrawal: Preterm birth, meconium staining(sgas and lgas too), long termeffects of deficits in attention, cognition, memory, and motor skills●Amphetamine withdrawal: Preterm or SGA, drowsiness, jitteriness, sleep patterndisturbances, respiratory distress, frequent infections, poor weight gain, emotionaldisturbances, and delayed growth and development●Alcohol withdrawal: Jitteriness, irritability, increased tone and reflex responses, andseizures●Tobacco: prematurity, low birth weight, increased risk for SIDS, increased for bronchitis,pneumonia, and developmental delaysInterventions:

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●Perform ongoing assessment of the newborn using neonatal abstinence scoring systemassessment●Elicit and assess newborn’s reflexes●Monitor thenewborn ability to feed and digest intake●Swaddle baby with legs flexed●Offernon-nutritive sucking(Pacifier)●Cluster care nursing●Monitor newborns fluids and electrolytes with skin turgor, mucous membranes,fontanels, daily weights, and I&O●Reduce environmental stimuli (dim light Gastrointestinal:poor feeding, regurgitation,diarrhea, excessive, uncoordinated sucking●s, lower noise level)Neonatal Abstinence scoring(Jaleya)●CNS:high pitched, shrill cry; incessant crying, irritability, tremors, hyperactivity withincreased moro reflex, increased deep tendon reflexes, increased muscle tone, disturbedsleep pattern, hypertonicity, convulsions●Metabolic, vasomotor, and respiratory:Nasal congestion with flaring, frequentyawning, skin mottling, retractions, sneezing, tachypnea <60, sweating, temp greater than99Newborn born to anHIV positive mother:(Destinee)Mom cannot breastfeed. HIV can be transmitted through milk. Formula feed.●Medications for baby○HEP B shot: 6-12 hrs after birth → because of compromised immunesystembath immediately○Zidovudine/Retrovir(protects baby from infection): liquid in mouth for 4-6 wks○Bactrim (prevent PCP) after 4-6 weeks○Bathed immediately after birth, does not go to mom (Same for Hep B +moms)○If parents refuse vitamin k they baby has to come back for circumcision○Virologic test done 14days, 21days, 1-2 months and 4-6 months■2 must be positive for baby to be diagnosed

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Indications for a cesarean birth:(Kayleigh)●Infections, ex.Active herpes●Complete placenta previa(nothing in vagina penis fingers)●Prolapsed cord(finger and push baby's head up)●Pattern of late deceleration●Breech position●Multifetal gestation (twin A position is transverse or breech)●Previous cesarean section (vertical incision on uterus) (only down low tranny)Newborn is born to a Hepatitis B positive mother. Describe the interventions used toprevent the baby from contracting Hepatitis B: (Joseph) P 122 in ATI●Vaccine: the hepatitis B vaccine and the hepatitis B immunoglobulin (HBIG)within 12hr of birth.●Immediate bath after birth●Recommended to be administered to all newborns. ●Informed consentmust beobtained. ● For newborns born to healthy women, recommended dosage schedule is atbirth, 1 month, and 6 months. The hepatitis B vaccine is given alone at 1 month, 2months, and 12 months. !it is important NOT to give the vitamin K and the hepatitisb injections in the same thigh. sites should be alternated in case of allergic reaction.Gonorrhea treatment during pregnancy(Karla)●Administererythromycinto all infants●Treat with ceftriaxone IM/Azithromycin PO: broad spectrum abx●Instruct client to: take all meds as prescribed, repeat culture to assess for medeffectiveness. There is a possibility of decreasing effectiveness of oral contraceptives*****REPORT THIS DISEASE to CDCCar Seat Safety: client education; term and premature newborn(Bukola)●Use an approved rear-facing car seat in the back seat, preferably in the middle (awayfrom airbags and side impact), to transfer the newborn.●Keep infants in rear-facing car seats until age 2 or until the child reaches the maximumheight and weight for the seat.●You as the nurseCAN NOTput baby in carseat, may demonstrate but then take baby out●25 to 45 degrees

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List your top 5 (priority) nursing actions following delivery of a normal newborn: (Crystal)●Throw baby on mom's chest and dry to prevent cold●External assessment:skin color, peeling (term), birthmarks(notify MD), foot creases(none in premature), breast tissue, nasal patency, and meconium staining (can indicatefetal hypoxia), Muscle Tone (preterm floppy, term flexed)●Chest:point of maximal impulse location; ease of breathing ; auscultation for heart rateand quality of tone; respirations for crackles, wheezes, and equality of bilateral breathsounds●Abdomen:rounded, umbilical cordone vein 2 arteries(“AVA”)●Neuro:muscle tone and reflex reaction, palpation for the presence and size of fontanelsand sutures , assessment of fontanels for fullness or bulge●Reflex irritability:grimace, cryExstrophy of the bladder: (nursing assessment and management): (Joseph)●avoid abduction of the infant’s legs,monitor peripheral circulation, provide meticulouswound & skin care( do not cover with any clothes on the part of exstrophy of the bladder). prevent infection and trauma to bladder(pre-op nursing care)●Care of the surgical site, monitor renal function ( post care)●Avoid moisten gauze,use a mist tent●6-8 wet diapers in one dayPlanning patient care: Cholecystitis &Cholelithiasis:(Kayleigh)Cholecystitis : inflammation of gallbladderCholelithiasis : hardeneddeposits within gallbladder●Common during pregnancydue to decreased gallbladder motility and increasedcholesterol saturation of bile●Associated with increased risk of preterm birth, maternal morbidity and readmission

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