ATI Maternal Newborn

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a newprescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A) "I can administer 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 minutes after the medication is inserted" D) "An antacid will be given 20 minutes prior to the insertion of the medication"

A) "I can administer oxytocin 4 hours after the insertion of the medication"

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? A) Abruptio placenta B) Placenta previa C) Preeclampsia D) Maternal bradycardia

A) Abruptio placenta

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? A) Depression B) Polyuria C) Hypotension D) Urticaria

A) Depression

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? A) Insert two gloved fingers into the vagina and apply upward pressure B) Wrap the visible cord tightly with sterile, dry gauze C) Apply oxygen to the client at 2 L/min via nasal cannula D) Place the client in the lithotomy position and apply fundal pressure

A) Insert two gloved fingers into the vagina and apply upward pressure

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption? Which of the following laboratory tests should the nurse expect the provider to prescribe? A) Kleihauer-Betke test B) Progesterone serum level C) Lecithin/sphingomyelin (L/S) ration D) Maternal Alpha-fetoprotein (AFP)

A) Kleihauer-Betke test

A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect? A) Reports increased urinary output B) Diaphoresis C) Reports blurred vision D) Shallow respirations

A) Reports increased urinary output

A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect? A) Reports increased urinary output B) Diaphoresis C) Reports blurred vision D) Shallow respirations

A) Reports increased urinary output

The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? A) The purpose of the NST is to assess the fetal CNS. B) The purpose of the NST helps to determine gestational age. C) The purpose of the NST is to determine fetal lie D) The purpose of the NST is to determine fetal breathing.

A) The purpose of the NST is to assess the fetal CNS.

Which of the following questions should the nurse ask to assess for true labor versus false labor? A) "When did your contractions begin?" B) "Have you noticed any bloody show or fluid coming from your vagina?" C) "What happens to your contractions when you move about?" D) "Have you felt fetal movement over the last 24 hours?"

B) "Have you noticed any bloody show or fluid coming from your vagina?" Rationale: 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. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes.Telling the client to walk is not a correct response because it is an intervention rather than an assessment question.

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? A) "My partner will put the condom on while his penis is erect." B) "I will remove the condom 30 minutes after intercourse." C) "My partner should leave an empty space at the tip." D) "I can use spermicidal gels or creams to increase effectiveness."

B) "I will remove the condom 30 minutes after intercourse." Rationale: 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 client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A) Administer antiviral medication B) Schedule an ultrasound examination C) Administer Haemophilus influenza type b vaccine D) Schedule an indirect Coombs' test

B) Schedule an ultrasound examination

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? A) "I should not remove the yellow exudate on the end of the penis." B) "I will clean his penis with each diaper change." C) "The circumcision will heal completely within a couple of weeks." D) "I can give him a tub bath in two days

D) "I can give him a tub bath in two days." Rationale: The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks.

A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? A) A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. B) Variable decelerations (not late decelerations) are associated with cord compression. C) Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. D) Late decelerations are associated with utero-placental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.

D) Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress. Rationale: The umbilical cord is wrapped tightly around the fetus' neckThe fetal cord is being compressed due to rapid descent of the fetal head Maternal contractions are not adequate enough to deliver the fetusThe fetus is not receiving adequate oxygen and is in distress

1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? A) Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. B) Numerous clots are abnormal and should be reported to the physician. C) Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. D) Lochia normally lasts for about 21 days, and changes from a bright red, topinkish brown, to creamy white.

D) Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. Rationale: The color of the lochia changes from a bright red to white after four days Numerous large clots are normal for the next three to four daysSaturation of the perineal pad with blood is expected when getting up from the bed Lochia should last for about 3 weeks, changing color every few days

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A) Apply a cool back for 10 minutes to the heel prior to the puncture B) Request a prescription for IM analgesic C) Use a manual lace blade to pierce the skin D) Place the newborn skin to skin on the mother's chest

D) Place the newborn skin to skin on the mother's chest

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? A) Administer penicillin G 2.4 million units IM to the client B) Instruct the client to schedule an annual pelvic examination C) Tell the client she will start medication for HIV immediately after delivery D) Report the client's condition to the local health department

D) Report the client's condition to the local health department