Review Ati maternal newborn assessment (2024)

Glucose 35 mg/dL: Incorrect. Hypoglycemia (glucose <40 mg/dL) is not directly related to cephalohematoma. The condition primarily affects bilirubin levels, not glucose.

Bilirubin 14.0 mg/dL: Correct. Cephalohematoma can lead to increased bilirubin levels as the accumulated blood breaks down, causing jaundice. This finding is consistent with the expected increase in bilirubin due to the condition.

Platelet count 350,000/mm³: Incorrect. A normal platelet count does not directly correlate with cephalohematoma. The platelet count given is within the normal range and is not indicative of the condition.

Hgb 9.9 g/dL: Incorrect. While anemia can occur in preeclampsia, it is not the primary laboratory finding associated with the condition. The hemoglobin level provided is low but not specific to preeclampsia.

Serum uric acid 2.5 mg/dL: Incorrect. Elevated serum uric acid levels are often associated with preeclampsia, but the value provided is below the normal range and would not be expected in this condition.

Casual blood glucose 228 mg/dL: Incorrect. Although gestational diabetes can occur, it is not a direct result of preeclampsia. The glucose level given is high but not specific to the condition.

Excessive high-pitched cry: Correct. A high-pitched cry is a common manifestation of NAS, indicating central nervous system irritability. This symptom, along with others, is consistent with withdrawal from opioids such as methadone.

Acrocyanosis: Incorrect. Acrocyanosis, which refers to the bluish discoloration of the hands and feet, is common in newborns but is not specific to NAS. It is typically a transient and benign condition.

Respiratory rate of 50/min: Incorrect. A respiratory rate of 50/min is within the normal range for a newborn and is not indicative of NAS. NAS is more commonly associated with symptoms such as irritability and abnormal crying.

Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.

Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.

Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.

Recommend a support group for the client to attend: Correct. A support group can provide the client with emotional support and practical advice from others who have experienced similar challenges. This can help the client cope with changes in body image and emotional responses.

Tell the client you are so sorry for how devastated they must feel: Incorrect. While showing empathy is important, this response does not actively address the client's concerns or provide practical support. It is more beneficial to offer concrete resources and coping strategies.

Tell the client to focus on their postoperative recovery for now: Incorrect. Although focusing on recovery is important, it is also crucial to address the client's emotional concerns about body image. Ignoring these concerns may affect their overall emotional well-being.

Teach the client about proper latching-on techniques: Correct. Proper latching-on techniques can help prevent further complications and ensure effective milk removal, which can help in managing mastitis and preventing recurrence.

Encourage the client to alternate breastfeeding with formula feeding: Incorrect. Breastfeeding should continue as usual because it helps to empty the breast and relieve engorgement, which is crucial for managing mastitis. Formula feeding could exacerbate the problem by increasing engorgement.

Instruct the client to avoid using a breast pump: Incorrect. Using a breast pump can be beneficial for managing mastitis by helping to relieve engorgement and ensure proper milk drainage. The pump should be used correctly and hygienically.

Encourage the client to allow their nipples to air dry after feedings: Correct. Allowing the nipples to air dry helps prevent further irritation and infection. It is important for maintaining skin integrity and comfort during mastitis.

History of breastfeeding: Incorrect. Breastfeeding is generally associated with a decreased risk of ovarian cancer. It is thought to reduce the number of lifetime ovulatory cycles, thereby potentially lowering the risk.

Previous use of oral contraceptives: Incorrect. The use of oral contraceptives is associated with a reduced risk of ovarian cancer. Long-term use can significantly decrease the risk, and the protective effect may continue for years after discontinuation.

History of breast cancer: Correct. A history of breast cancer is a risk factor for ovarian cancer, particularly in women with BRCA1 or BRCA2 gene mutations. These mutations increase the risk of both breast and ovarian cancers.

Use of postmenopausal estrogen: Correct. The use of postmenopausal estrogen, especially when used without progesterone, is associated with an increased risk of ovarian cancer. Estrogen therapy can stimulate the growth of ovarian tumors in susceptible women.

Sliced apples: Correct. Sliced apples are low in phenylalanine and safe for individuals with PKU. Fruits are generally recommended for PKU patients as they provide essential nutrients without significant amounts of phenylalanine.

Glass of skim milk: Incorrect. Milk, including skim milk, contains phenylalanine, which should be limited or avoided by individuals with PKU. They need to consume specially formulated low-phenylalanine products.

Scrambled egg: Incorrect. Eggs are high in phenylalanine and should be avoided by individuals with PKU. They need to choose low-protein alternatives that do not contribute to their phenylalanine levels.

Assist with performing a vagin*l/speculum exam to check for a prolapsed umbilical cord: Incorrect. Although checking for umbilical cord prolapse is important, the first action should be to address any potential causative factors like oxytocin use before performing an examination.

Discontinue the infusion of oxytocin: Correct. Recurrent variable decelerations can be a sign of umbilical cord compression, often exacerbated by excessive uterine contractions induced by oxytocin. Discontinuing the infusion is a critical first step to alleviate the pressure on the umbilical cord and improve fetal heart rate patterns.

Provide instructions for the client about potential preparation for birth: Incorrect. Providing instructions about preparation for birth is important but does not address the immediate issue of recurrent variable decelerations and their potential cause.

"I will receive the shot after delivery if my baby is Rh-negative.": Incorrect. Rho(D) immune globulin is given after delivery if the baby is Rh-positive. If the baby is Rh-negative, the shot is not necessary.

"I should not receive any immunizations for 3 months after the shot.": Incorrect. There are no restrictions on receiving other immunizations after receiving Rho(D) immune globulin, and there is no need to wait for 3 months.

"This shot may be given after birth to protect future pregnancies.": Correct. Rho(D) immune globulin is given postpartum if the baby is Rh-positive to prevent the development of antibodies that could affect future pregnancies.