ATI Maternal exam questions

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Näegele's rule, which expected date of delivery should the nurse document in the client's chart? 1.July 12, 2021 2.July 26, 2021 3.August 12, 2021 4.August 26, 2021

2

A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (SATA) a. Client has delivered one newborn at term b. Client has experienced no preterm labor c. Client has been through active labor d. Client has had two prior pregnancies e. Client has one living child

A., D., E.

A laboring client reports suddenly feeling something in her vagina. Upon assessment, the nurse identifies a prolapsed umbilical cord. Place the following interventions in the correct order that they should be performed for this client. A. Prepare the client for a cesarean birth. B. Administer oxygen at 8-10L via face mask. C. Notify primary care provider of the prolapsed cord. D. Reposition the client in either a knee-ches or Trendelenburg position. E. Using a sterile glove insert two fingers into the vagina to reduce pressure off the cord.

C, D, E, B, A Notifying the health care provider and staff is the first priority and facilitates readiness for further interventions. D. Next step will be to remove pressure from the cord by repositioning client. E. Inserting fingers into the vagina and applying finger pressure to the fetal presenting part reduces pressure on the umbilical cord and provides oxygenation to the fetus. B. Administration of supplemental oxygen will further improve fetal oxygenation. A Emergent care of the client and fetus is priority and if all other measures fail, the client should be prepared for a cesarean birth.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1.A normal test result 2.An abnormal test result 3.A high risk for fetal demise 4.The need for a cesarean section

1

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1."I will need to increase my insulin dosage during the first 3 months of pregnancy." 2."My insulin dose will likely need to be increased during the second and third trimesters." 3."Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4."My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1.Changes in vital signs 2.Signs of heavy bruising 3.Complaints of intense pain 4.Complaints of a tearing sensation

1 Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1 The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1.Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL/day. 4.Continue to breast-feed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breast-feeding or breast pump.

1 2 3 4

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function 5.Prevents large particles such as bacteria from passing to the fetus 6.Provides an exchange of nutrients and waste products between the mother and the fetus

1 2 3 4 The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1 2 3 6

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1. A primigravida with abruptio placenta 2. A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 4.A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

1 3 5

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

1. Notify the primary health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

1.The mother requests that the window be closed before feeding. 2.The mother holds the newborn properly during feeding and burping. 3.The mother tests the temperature of the formula before initiating feeding. 4.The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1.Therapeutic abortion is required. 2.Isoniazid plus rifampin will be required for 9 months. 3.She will have to stay at home until treatment is completed. 4.Medication will not be started until after delivery of the fetus.

2

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1.Soft abdomen 2.Uterine tenderness 3.Absence of abdominal pain 4.Painless, bright red vaginal bleeding

2

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1.The client is a 35-year-old primigravida. 2.The client has a history of cardiac disease. 3.The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4.The client is a 20-year-old primigravida of average weight and height.

2

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? 1.Hemoglobin of 11 g/dL (110 mmol/L) 2.Fetal heart rate of 180 beats per minute 3.Maternal pulse rate of 85 beats per minute 4.White blood cell count of 12,000/mm3 (12 × 109/L)

2 A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1.Document the findings. 2.Notify the obstetrician (OB). 3.Reassess the client in 2 hours. 4.Encourage increased oral intake of fluids.

2 Clots larger than 1 cm are considered abnormal.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1."Come to the clinic immediately." 2."The vaginal discharge may be bothersome, but is a normal occurrence." 3."Report to the emergency department at the maternity center immediately." 4."Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours.

2 Leukorrhea begins during the first trimester. Many clients notice a thin, colorless, or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1.Encourage the mother to breast-feed soon after birth. 2.Support the mother in her reaction to the newborn infant. 3.Tell the mother that it is important to hold the newborn infant. 4.Document a complete account of the mother's reaction on the birth record.

2 Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1.Ambulation 2.Rest between contractions 3.Change positions frequently 4.Consume oral food and fluids

2 The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1."I will record the number of movements or kicks." 2."I need to lie flat on my back to perform the procedure." 3."If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." 4."I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

2 can either sit or lie down if less than 10 kicks in two consecutive 2 hour counts contact the DR

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1."It promotes the fertilized ovum's chances of survival." 2."It promotes the fertilized ovum's exposure to estrogen and progesterone." 3."It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4."It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

3

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? 1.Document the finding. 2.Check the mother's heart rate. 3.Notify the obstetrician (OB). 4.Tell the client that the fetal heart rate is normal.

3

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding 1.The client is measuring large for gestational age. 2.The client is measuring small for gestational age. 3.The client is measuring normal for gestational age. 4.More evidence is needed to determine size for gestational age.

3 During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a −2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1.Less pressure on her cervix 2.Decreased number of contractions 3.Increased efficiency of contractions 4.The need for increased maternal blood pressure monitoring 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

3 5 Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply . 1.It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.

3 5 The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1.Variability 2.Accelerations 3.Early decelerations 4.Variable decelerations

4

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1."I should breast-feed every 2 to 3 hours." 2."I should change the breast pads frequently." 3."I should wash my hands well before breast-feeding." 4."I should wash my nipples daily with soap and water."

4 Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura

4 Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

4 5 6

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1."Your type of pelvis has a narrow pubic arch." 2."Your type of pelvis is the most favorable for labor and birth." 3."Your type of pelvis is a wide pelvis, but it has a short diameter." 4."You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

A nurse is teaching a new mother breastfeeding techniques. Which of the following teaching tips are appropriate to discuss with a new mother who is breastfeeding? Select all that apply. Select one or more: a. Burp the newborn between each breast. b. Dark, firm stools are the norm. c. Avoid a specific length of time to breastfeed. d. Two to three wet diapers per day are the norm. e. Avoid use of a pacifier to prevent nipple confusion. ng or syringe feeding, if needed.

Show the mother how to burp the newborn when she alternates breasts. The newborn should be burped either over the shoulder or in an upright position with his chin supported. The mother should gently pat the newborn on his back to elicit a burp. Avoid educating mothers regarding the duration of newborn feedings. Mothers should be instructed to evaluate when the newborn has completed the feeding, including slowing of newborn suckling, a softened breast, or sleeping. Tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers. Supplementation can be provided using a small feeding or syringe feeding, if needed.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? 1.Notify the primary health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.

The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

Levonorgestrel contraception - which of the following should you teach about this medication? a. "you should take the medication within 72 hours following unprotected sex." b. "you should avoid taking this medication if you are on an oral contraceptive" c. "If you dont start your period within 5 days of taking this medication, you will need a pregnancy test." d. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

a Levonorgestrel is an emergency contraceptive

A client in her first trimester is encouraged to increase intake of proteins and folic acid as essential nutrients for basic fetal growth. Which foods would the nurse identify as high in folic acid? Select one: a. Lentils b. Tomatoes c. Fish Incorrect d. Avocados

a

A nurse in a health clinic is reviewing contraceptive use with a group of adolescent clients. Which of the following statements by an adolescent reflects an understanding of the teaching? a. "A water-soluble lubricant should be used with condoms." b. "A diaphragm should be removed 2 hours after intercourse." c. "Oral contraceptives can worsen a case of acne." d. "A contraceptive patch is replaced once a month."

a

A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? Select one: a. Maternal history of cytomegalovirus. b. Increased size of neonate's heart. c. Documented birth trauma. d. A decreased number of functional alveoli.

a Cytomegalovirus can be transferred via the placenta directly onto the fetal circulatory system and transmitted directly from infected amniotic fluid.

Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? Select one: a. Stop oxytocin infusion and assess contractions and fetal heart rate. b. Assess vital signs and apply O2 via facemask. c. Stop the oxytocin infusion and administer terbutaline 0.25 mg. d. Notify provider and prepare for an emergency cesarean birth

a If there are any signs of fetal or maternal distress the priority intervention would be to stop the Pitocin infusion. Pitocin should be discontinued with any of the following: prolonged or excessively strong contractions; signs of any fetal hypoxia and or fetal distress; signs of uterine or placenta abruptio; evidence of an antidiuretic affect; and hypertension

A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? Select one: a. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes b. B/P 138/80mmHg, contractions every 3-4 minutes c. FHR 140 b/min: good variability, contractions every 3-4 minutes d. B/P 110/60mmHg, trace protein, contractions every 3-4 minutes

a Late decelerations are signs of placental insufficiency which can cause fetal hypoxemia. The nurse should notify PCP immediately.

A nurse in a pernatal clinic is assessing a group of clients. which of the following should the nurse see first? a. a client who is at 11 weeks of gestation and reports abdominal cramping. b. a client who is at 15 weeks of gestation and reports tingling and numbness in right hand c. a client who is at 20 weeks of gestation and reports constipation for the past 4 days d. a client who is at 8 weeks of gestation and reports having three bloody noses in the past week

a abdominal cramping can indicate ectopic pregnancy or manifestations of spontaneous abortion

26 week preterm. which of the following findings should the nurse expect? a. minimal arm recoil b. popliteal angle of 90 c. creases over the entire foot sole d. raised areolas with 3 - 4 mm buds

a also will have decreased muscular tone

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misprostol. Which of the following instructions should the nurse include in the teaching? a. I can admin oxytocin 4 hours after the insertion of the medication b. you will need a full bladder prior to the insertion of the medication c.Remain in a side-lying position for 15 mins after med is inserted d. an antacid will be given 20 minutes prior to the insertion of the medication

a do not admin oxytocin any sooner than 4 hours remain in side lying for 30-40min

A nurse in an infertility clinic is providing care to a couple who has been unable to conceive for 18 months. Which of the following data should be included in the assessment? (SATA) a. Occupation b. Menstrual history c. Childhood infectious diseases d. History of falls e. Recent blood transfusions

a b c

A nurse is providing prenatal education to a group of pregnant women. The nurse is teaching clients when to contact their provider. Which of the following should be included? Select all that apply. Select one or more: a. Severe continuous headeaches b. Epigastric pain c. Dimming vision d. Chloasma e. Evening lower extremity edema.

a b c All are possible symptoms of pregnancy induced hypertension. A severe and continuous headache along with visual changes could indicate CNS irritability and possible onset of seizures. Epigastric pain could indicate impending HELLP syndrome.

which of the following is a contraindication to oral contraceptives? (SATA) a. cholecystitis b. hypertension c. Human papillomavirus d. Migraine Headaches e. Anxiety disorder

a b d

A nurse is educating a client who is scheduled for a nonstress test (NST). Which of the following statements are correct? Select all that apply. Select one or more: a. The NST can easily be performed in an outpatient setting. b. The NST is a primary method of antenatal fetal assessment. c. The NST is a useful in calculating gestational age. d. The NST measures the relationship of the fetal heart rate to fetal movement. e. The NST is not useful after 38 weeks gestation.

a b d CORRECT: The NST is a noninvasive test which is easily performed in outpatient settings. CORRECT: In most settings the NST has become an ideal screening test for fetal well being. CORRECT: The basis of the NST is the principle that the normal fetus will produce characteristic HR patterns in relationship to fetal movement.

A nurse is caring for a client immediately following an amniotomy. Which of the following interventions are appropriate? Select all that apply. Select one or more: a. Observe for the presence of an odor in amniotic fluid. b. Assess fetal heart for rate and variable decelerations. c. Assess maternal intake and urinary output. d. Document any unusual color in the amniotic fluid. e. Prepare for an intrauterine pressure catheter (IUCP) insertion.

a b d CORRECT: The presence of a foul odor in maternal fluid can be an important sign of infection. CORRECT: After an amniotomy everything shifts in the uterus and the cord may become compressed. The nurse should immediately assess the fetal heart following the procedure. CORRECT: Any color in particular any meconium stained fluid or blood can indicate fetal distress.

A nurse is educating a client on how to perform Kegel exercise therapy for urinary incontinence. Which of the following points should be included in teaching? Select all that apply. Select one or more: a. During exercises, tighten pelvic muscles for a count of 10 and then relax for a count of 10. b. Complete exercises in only a sitting position. c. Have a designated time and place for completing therapy. d. While sitting on the toilet, strain down to help identify pelvic muscles. e. Improvement in incontinence may be seen after 6 weeks of exercise therapy.

a c CORRECT. The client should be educated to tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10. This exercise should be done 15 times while lying down, sitting up, and standing (a total of 45 exercises). The client should then repeat the exercises rapidly contracting and relaxing the pelvic muscles 10 times. This should take no longer than 10 to 12 minutes for all three positions, or 3 to 4 minutes for each set of 15 exercises. CORRECT. At first, it is helpful to have a designated time and place to do exercises because the client will need to concentrate to do them correctly. CORRECT. Although improvement may take several months, most clients notice a positive change after 6 weeks of exercises. Incorrect. To identify pelvic muscles, the client should be educated to sit on the toilet with feet flat on the floor about 12 inches apart. The client should begin to urinate and then try to stop the urine flow. The client should not strain down, lift her bottom of the seat, or squeeze her legs together. When stopping the urine stream in this position, the pelvic muscles are utilized.

A nurse is preparing to administer oxytocin to a client who is postpartum. which of the following is an indication of the medication? (SATA) a. flaccid uterus b. cervical laceration c. excess vaginal bleeding d. increased afterbirth cramping e, increased maternal temperature

a c oxytocin will increase rather than decrease, afterbirth cramping

A nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the following are expected findings for this client? Select all that apply Select one or more: a. Weight loss b. Increased blood pressure c. Ketosis d. Dehydration e. Persistent diarrhea

a c d Hyperemesis gravidarum is excessive nausea and vomiting (related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis. Dehydration would lead to a decrease in blood pressure and increase in pulse

A nurse is administering magnesium sulfate to a client diagnosed with preeclampsia. Which of the following signs and symptoms would indicate possible magnesium toxicity? Select all that apply. Select one or more: a. Prolonged PR interval b. Hypertension c. Hyperactive tendon reflexes d. Diminished tendon reflexes e. Hypotension

a d e Magnesium Sulfate reduces striated muscle contractions due to a depressant effect on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate include diminished tendon reflexes, hypotension and prolonged PR intervals. Magnesium Sulfate reduces striated muscle contractions due to a depressant effect on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate include diminished tendon reflexes, hypotension and prolonged PR intervals. Magnesium Sulfate reduces striated muscle contractions due to a depressant effect on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate include diminished tendon reflexes, hypotension and prolonged PR intervals.

A nurse is teaching a client the correct use a diaphragm as a method of contraception. Which of the following statements is correct? Select one: a. Douche promptly after removing the diaphragm b. Leave diaphragm in place for at least 6 hours post coitus c. Insert diaphragm at least 8 hours prior to sexual intercourse d.Do not use any cream or jelly with the diaphragm

b

A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? Select one: a. The medication dose should be increased b. The drug is having a therapeutic effect c. Deep tendon reflexes should be assessed d. The medication dose should be decreased

b A cessation of labor is the desired therapeutic effect of a tocolytic. While deep tendon reflexes should be assessed with a client is receiving magnesium sulfate this is not required based on this data.

1 day postpartum and has a vaginal hematoma. which of the following manifestations should the nurse expect? a. lochia serosa vaginal drainage b. vaginal pressure c. intermittent vaginal pain d. yellow exudate vaginal drainage

b PT who has vagina hematoma to report pressure in the vagina due to the blood that leaked into the tissues

A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an appropriate psychological task for the client? Select one: a. Begin to think about names for the baby b. Accept the fact that she is pregnant c. Verbalize concerns about the health care facility d. View morning sickness as tolerable

b The developmental task during the first trimester is to accept the reality of the pregnancy. Accepting the reality of being pregnant allows the client to see a provider and get prenatal care.

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "Have you felt fetal movement over the last 24 hours?" d. "What happens to your contractions when you move about?

b Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.

PT is having an amniotomy. Which of the following assessments should the nurse identify as the priority? a.O2 saturation b.Temperature c.Blood pressure d.Urinary output

b the greatest risk is an infection

A nurse in a clinic is teaching a client about her new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (SATA) a. "Weight loss can occur." b. "You are protected against STIs" c. "You should increase your intake of calcium." d. "You should avoid taking antibiotics." e. "Irregular vaginal spotting can occur."

b c

What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound? Select all that apply. Select one or more: a. Fetal tidal volume b. Reactive FHR c. Qualitative amniotic fluid volume d. Fetal tone e. Fine body movement

b c d Fetal tone, relative FHR, fetal breathing movements, gross body movements, fetal tone and qualitative amniotic fluid volume are physical and physiological characteristics of the BPP.

A nurse is caring for a newborn client who is experiencing severe hyperbilirubinemia. Which of the following are symptoms of kernicterus? Select all that apply. Select one or more: a. Low birth weight b. Backward arching of the neck and trunk c. Hypotonic d. Temperature instability e. Lethargy

b c e Kernicterus (bilirubin encephalopathy) can result from untreated hyperbilirubinemia with bilirubin levels at or higher than 25 mg/dL. It is a neurological syndrome caused by bilirubin depositing in brain cells. Survivors may develop cerebral palsy, epilepsy, or mental retardation. They may have minor effects such as learning disorders or perceptual-motor disabilities. Symptoms can include lethargy, hypotonia, high-pitched cry and tonic motions such as backwards arching of the next and trunk. Low birth weight and temperature instability are not symptoms associated with kernicterus.

A nurse is caring for a neonate who is 34 weeks gestation. The nurse correctly understands which of the following are consistent with prematurity? Select all that apply. Select one or more: a. Mongolian spots on shoulders b. Prominent clitoris and labia minora c. Large amount of vernix present d. Inner eye canthus level with pina e. Abundant lanugo

b c e Prominent clitoris and labia minora - These findings are seen with prematurity. Large amounts of vernix are noted with prematurity. Noted in abundant amounts with a premature newborn.

A nurse is caring for a prenatal client who has parvovirus B19 (fith disease). Which of the following action should the nurse take? a. admin antiviral medication b. schedule ultrasound examination c. admin haemophilu influenzae type b vaccine d.schedule coombs test

b. schedule ultrasound examination to monitor the fetus during the pregnancy

A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? a. "You will need to see a genetic counselor as part of the assessment." b. "It is usually the woman who is having trouble, so the man doesn't have to be involved." c. "The man is the easiest to assess, and the provider will usually begin there." d. "Think about adopting first because there are many babies that need good homes."

c

A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following? a. Reduced menstrual flow b. Breast tenderness c. SOB d. Headaches

c

thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Select one: a. Obtain an order for a drug screening blood test. b. Hold and comfort the infant to stop the crying. c. Perform a heel stick to check serum glucose. d. Feed the infant oral feeding.

c

A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? Select one: a. Diminished tendon reflexes b. Negative Startle reflex c. Hypothermia d. Increased drowsiness

c Thermal regulation issues are noted with this condition, such as hypothermia or hyperthermia.

Which of the following statements should the nurse include in the teaching for universal newborn screening? a. obtain an informed consent prior to obtaining the specimen b. collect at least 1 ml for the the urine test c. ensure the newborn has been receiving feedings for 24 hr prior to obtaining the specimen d. premature newborns may have false negative test due to immature development of liver enzymes.

c also it is a heel stick blood test mandated by law so consent is not needed

26 week gestation and has epilepsy. the PT has a seizure. After turning the client's head to one side which of the following actions should the nurse take immediately after the seizure? a. monitor FHR b. assess uterine activity c. admin O2 via a nonrebreather mask d. start a bolus of IV fluid

c use the ABC approach

A nurse in a OB clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? a. "An IUD should be replaced annually during a pelvic exam." b. "I cannot get an IUD until after I've had a child." c. "I should expect intermittent abdominal pain while the IUD is in place." d. "A change in the string length of my IUD is unexpected."

d

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? a. "let me help you into a comfortable pushing position so you can begin bearing down." b. I am going to call the doctor to get a prescription for medication to ripen your cervix." c. I will give you some IV pain medicine to strengthen your contractions." d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

d

breastfeeding mother develops engorgement on her second postpartum day. Which of the following statements by the client indicates a need for further teaching? Select one: a. I will use a breast pump if my breasts do not soften. b. I will feed my baby every 2 hours. c. I will apply warm packs to each breast prior to feeding d. I will offer my baby a bottle following each feeding.

d Bottle feeding while breastfeeding could lead to nipple confusion and interfere with successful breastfeeding. This mother needs further teaching.

A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? Select one: a. The fundus will be one centimeter above the umbilicus. b. The fundus will be two centimeters below the umbilicus. c. The fundus will be at the level of the umbilicus. d. The fundus will be one centimeter below the umbilicus.

d The fundus descends 1-2 cms per day, so from the highest point of 1 cm above the umbilicus at 12 hours, it should be 0 to 1 cms below the umbilicus on day two

A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is the correct position? Select one: a. Left lateral position with a foam wedge between the legs. b. Lithotomy position with a foam wedge behind the shoulders. c. Modified Trendelenburg position with a foam wedge under the legs. d. Supine position with foam wedge positioned under one hip.

d The supine position is appropriate for abdominal surgery (cesarean birth), and a wedge under one hip laterally tilts the client and reduces uterine weight on the vena cava and descending aorta. This helps maintain optimal perfusion of oxygenated blood to the fetus during the procedure.

Which of the following condom statements by a client represents a need for further teach? a. I can use spermicidal gels or creams to increase effectiveness b. my party should leave an empty space at the tip c. My partner will put the condom on while his penis is erect d. I will remove the condom 30 minutes after intercourse

d To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina.

A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? Select one: a. Absence of fetal heart tones and fetal movement. b. Steady bleeding with lower abdominal pain.. c Edematous face, hands, and ankles. d. Unilateral stabbing abdominal lower abdominal pain.

d as the fetus develops, it eventually exceeds the diameter of the fallopian tube and ruptures the tube, creating an internal hemorrhage. There may or may not be blood from the vagina. The symptoms may include unilateral stabbing pain and tenderness in the lower abdominal quadrant, and commonly referred shoulder pain from blood irritation of the diaphragm or phrenic nerve. There may be nausea and vomiting, and symptoms of shock.

A nurse is assessing a late preterm newborn. which of the following manifestations is an indication of hypoglycemia? a. Hypertonia b. Increased feeding c. Hyperthermia d. respiratory distress

d other manifestations include abnormaly cry, jitteriness, lethargy, poor feeding, apnea, and seizures

Which of the following newborns should the nurse report to the provider? a. a newborn who is 26 hour old and has eyrthema toxicum on his face b. a newborn who is 32 hr old and has not passed a meconium stool c. a newborn who is 12 hr old and has pink-tinged urine d. a newborn who is 18 hr old and has an axillary temp. of 37.7 C (99.9F)

d outside the range of 37.5 (99.5)

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take? a. perform a vaginal exam to determine cervical dilation every 2 hr b. instruct the client to ambulate in the hallway once every 4hr c. administer betamethasone to the client via IM injection d. initiate continuous external fetal monitoring

d bethasone to the client via IM injection is given for 24-34 week