Maternal Newborn ATI Quizlet

Correct Answer: A

Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.

Correct Answer: C

Rationale: Plantar creases covering 2/3 of the sole is an important physical characteristic used to assess gestational age in a newborn. This finding is significant because as gestational age advances, the plantar creases cover a larger portion of the sole. It is a valuable clue to the healthcare provider in determining the newborn's maturity level. Choices A, B, and D are incorrect as they do not specifically relate to gestational age assessment. Acrocyanosis and vernix caseosa are common findings in newborns but are not directly used for determining gestational age. The softness and level of the anterior fontanel can provide information about intracranial pressure but are not directly related to gestational age assessment.

Correct Answer: A

Rationale: Assessing the firmness of the uterus is crucial in this situation. A uterus that is not firm could indicate postpartum hemorrhage, a common cause of low blood pressure after childbirth. By evaluating the firmness of the uterus, the nurse can quickly identify and address potential complications, such as excessive bleeding. Initiating oxygen therapy, administering oxytocin infusion, or obtaining a type and crossmatch may be necessary interventions later, but assessing the firmness of the uterus takes precedence as the first step in managing postpartum complications.

Correct Answer: D

Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall, which can cause continuous abdominal pain and vaginal bleeding. In this scenario, the client's symptoms of sudden abdominal pain and vaginal bleeding are indicative of abruptio placentae, which requires immediate medical attention to prevent potential complications for both the client and the fetus. Placenta previa is characterized by painless vaginal bleeding in the third trimester, not sudden abdominal pain. Prolapsed cord presents with visible umbilical cord protruding from the vagina and is not associated with abruptio placentae symptoms. Incompetent cervix typically manifests as painless cervical dilation in the second trimester, not sudden abdominal pain and bleeding as seen in abruptio placentae.

Correct Answer: A

Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.