ATI RN MATERNAL NEWBORN A EXAM WITH EXPLANATIONS 

ATI RN MATERNAL NEWBORN A EXAM WITH EXPLANATIONS 

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid 
replacement. Which of the following findings should the nurse report to the provider?
correct-a. BUN 25 mg/dL
rationale 
The nurse should report an elevated BUN to the provider since it can indicate 
dehydration.
A nurse is assessing four newborns. Which of the following findings should the nurse 
report to the provider?
correct -d. a newborn who is 18 hr old and has an axillary temperature of 37.7 degrees 
Celsius
rationale 
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference 
range for a newborn and can be an indication of sepsis. Therefore, the nurse should 
report this finding to the provider.
A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the 
following findings should the nurse report to the provider? Select the 3 findings that 
should be reported? - correct -Uterine contractions is correct. 
rationale 
The client is experiencing regular uterine contractions and cervical change, which are 
indicators of preterm labor; therefore, the nurse should notify the provider about this 
finding.
Fetal heart rate is incorrect. The fetal heart rate is within the expected reference 
range; therefore, the nurse should not report this finding to the provider.
Gestational age is correct. The client is at 32 weeks of gestation and is experiencing 
regular uterine contractions and cervical dilation, which indicates that the client is in 
preterm labor; therefore, the nurse should notify the provider about this finding.
Vaginal examination is correct. The client's cervix is dilated to 2 cm and is 50% effaced, 
which indicate the client is in preterm labor; therefore, the nurse should notify the 
provider about this finding.
Maternal blood pressure is incorrect. The client's blood pressure is within the expected 
reference range; therefore, the nurse should not report this finding to the provider.
For each assessment finding, click to specify if the finding is consistent with 
hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one 
disease process. - correct -Decreased temperature is associated with hypoglycemia 
and sepsis.
rationale 
Yellow sclera and oral mucosa are associated with hyperbilirubinemia and sepsis. Poor 
feeding is associated with hypoglycemia, hyperbilirubinemia and sepsis. Ecchymosis 
caput succedaneum is associated hyperbilirubinemia. Respiratory distress is associated 
with hypoglycemia and sepsis. Lethargy is associated with hypoglycemia and sepsis.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about 
management during pregnancy. Which of the following statements by the client 
indicates an understanding of the teaching?
- correct -c. "I will continue taking my insulin if I experience nausea and vomiting."
 
 
rationale 
The nurse should teach the client to continue to take their insulin as prescribed during 
illness to prevent hypoglycemic and hyperglycemic episodes.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which 
of the following findings should the nurse report to the provider as a potential 
complication?
- correct -b. leakage of fluid from the vagina
rationale 
Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and 
should be reported to the provider.
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 
3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of 
methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F) 
Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F) 
Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier 
but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. 
Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive 
Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn urine toxicology 
screen positive for opiates (- - ANSWER-Respiratory findings is incorrect. The newborn's 
respiratory rate is within the expected reference range of 30 to 60/min. There is no 
indication the newborn has an alteration in respiratory status; therefore, this finding 
does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference 
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be 
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected 
reference range of greater than 94%; therefore, this finding does not need to be 
reported to the provider.
Central nervous system findings is correct. The newborn is displaying inconsolability, 
high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and
excessive sucking. These findings are manifestations of NAS and should be reported to 
the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose 
stools. These findings are manifestations of NAS and should be reported to the provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear upon 
awakening. Client denies contractions or abdominal pain. External fetal monitor 
applied.
@0930: Client passed large amount of bright red blood from vagina. Denies pain. Uterine 
tone soft and nontender to palpation. Contraction pattern: no contractions noted. Fetal 
heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No 
decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood 
pressure 112/64 mmHg. Fetal heart rate 132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min
Exhibit 3: Medical hx
G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section -
ANSWER-When generating solutions, inserting a large bore intravenous catheter is 
indicated. Clients who have third trimester vaginal bleeding may experience a sudden 
hemorrhage and require fluid resuscitation or the administration of blood products. The 
nurse should weigh perineal pads. Weighing perineal pads after use will provide a more 
accurate assessment of the volume of blood loss that the client is experiencing.