ATI Maternal Newborn Practice 2016B

A nurse is teaching a client who has pregestational type 1 diabetes about management during pregnancy. Which of the following statements by the client indicate an understanding of teaching?

"I will continue taking my insulin if i experience nausea or vomiting" The reason being that the nurse should teach the client to continue taking insulin as perscribed even when sick to prevent any hyper or hypoglycemic episodes.

A nurse is teaching a group of parents about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?

"I will dress my baby in flame retardant clothing" The parents should dress their newborns in flame-retardant clothing to prevent injury.

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of teaching?

"I will eat foods that appeal to my taste, instead of trying to balance my meals" Clients who have hyperemesis gravidarum should eat to taste to avoid nausea

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

"You should take the medication 72 hours following unprotected sexual intercourse" Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is teaching a client who is 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching?

"You will be offered orange juice to drink during the test" A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain results.

A nurse is teaching a client who is 24 weeks of gestation regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

A blood glucose of 130-140 is considered a positive screening result The nurse should teach the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

A nurse is assessing newborns, which should she report to the provider?

A newborn with an axillary temp of 99.5 or above, this could indicate sepsis.

A clients fundus is deviated to the right, 2 fingerbreaths above the umbilicus, and is less firm than previously noted. What should the nurse instruct the client to do first?

Assist the client to the bathroom to void. Always invasive first.

A nurse is caring for a client who is 40 weeks gestation and in early labor. The client has a platelet count of 75,000/mm and is requesting pain relief. Which of the following treatment modalities should the nurse antecepate?

Attention-focusing Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.

Blotchy hyperpigmentation on the forehead of a pregnant mom

Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives Migraine headaches is correct. A history of migraine headaches is a contraindication for the use or oral contraceptives.

A nurse is assessing the client who is in active labor and notes early decelerations in the FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take?

Continue monitoring the client Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse should continue to monitor the client.

A nurse is performing a vaginal exam on a client in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best nonpharmalogical intervention to perform to relieve the clients discomfort?

Counter pressure According to evidence-based practice, counter-pressure is the best nonpharmacological technique to use when relieving the client's discomfort from the fetus being in a posterior position because this intervention lifts the fetal head off of the spinal nerve.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Cover the newborns eyes while under the phototherapy light Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect?

Creases over two-thirds of the soles of the feet is correct. Fewer creases over the soles of the feet is an indication of prematurity. Creases over the entire soles of the feet is an indication of postmaturity. Molding of the head is correct. Molding occurs during the birth process as the newborn travels through the birth canal, resulting in compression of the soft bones of the skull.Lanugo on the shoulders is correct. Absence of lanugo is an indication of postmaturity. Abundant lanugo is an indication of prematurity.

A nurse is assessing a client who is 26 weeks pregnant, which of the following clinical manifestations should the nurse report to the provider?

Decreased urine output decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be indications of preeclampsia and should be reported to the provider.

A nurse is planning care for a client who is 2 hrs postpartum. Which of the following interventions should the nurse plan to implement during the "taking-hold" phase of the postpartum behavioral adjustment?

Demonstrate to a client how to perform a newborn bath. "Taking-hold phase"

A nurse is assess a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?

Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.

A client is 8 weeks gestation. What should the nurse instruct for the client to take?

Iron, folic acid

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

A nurse is caring for a client who has uterine hypotonicity and is experiencing a post partum hemorrhage. Which of the following actions is the nurses priority?

Massage the clients fundus Uterine hypotonicity and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, causing death to occur. Therefore, the nurse's priority is to massage the client's fundus in order to minimize blood loss

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect?

Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.

A nurse in a providers office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?

Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

A nurse is assessing a full term newborn 15min after birth. Which of the following findings require intervention by the nurse?

Resp rate of 18 During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this time requires further evaluation and intervention by the nurse During the first 30 min a heart rate of 160-180 is expected. During the first 30, crying, jerking, tremors, crackles on auscultation is okay.

A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a clinical manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

Which of the positions should the nurse recommend to increase the circulation to the placenta?

Side-lying In order to increase placental circulation, the nurse should recommend the side-lying position to a client who is pregnant, which avoids the compression of the vena cava. Decreased circulation in the uterus can lead to having a child who is small for gestational age.

A nurse is teaching a mother how to use the bulb syringe on the newborn. Which of the following instructions should the nurse include?

Stop suctioning when the newborns cry sounds clear The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

A nurse is assessing a newborn who is 12hr old. Which of the following clinical manifestation requires intervention by the nurse?

Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This clinical manifestation requires further assessment and intervention by the nurse

A nurse is assessing a client who is at 38 weeks of gestation, what should the nurse report to the provider during this prenatal visit?

That she gained 2.2kg (4.8ibs) in one week indicates a complication may be going on.

How does the nurse perform leopold maneuvers?

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is performing a vaginal examination for a client who is in active labor and reports back pain. The nurse determines the client is 8cm dilated, 100% effaced, and -2 station and the fetus is in the occiput posterior position. Which of the following actions should the nurse take?

The nurse should assist the patient into the hands and knees position, which might help with the pain and enable to fetus to turn from posterior to anterior position

A nurse is providing discharge to a client who had a c section 3 days ago. Which of the following instructions should the nurse include prior to discharge?

The nurse should let the mother know that she can still become pregnant even though she is breastfeeding. She should offer an insight on the use of contraception. It can take up to 6 weeks for the c section to heal

After they give the epidural, what should the nurse do?

The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is providing discharge teaching to a parent whose newborn has just had a circumcision. Which of the following instructions should the nurse include?

The parent should inspect the insicion every 4 hours and if it lightly bleeds, the parent should apply slight pressure with sterile gauze for mild bleeding

A nurse is speaking to a client who is trying to make a decision about uterine tube occlusion. The client asks, "what effects will this have on my sex life?". Which of the following responses should the nurse make?

The process should have no affect on the sexual function or adequacy. It is a type of contraception and can actually have them enjoy it more bc they do not have the fear of getting pregnant

A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2-3min apart, each lasting 80-90 seconds long, and a vaginal exam shows that she is 9cm dilated. The nurse should identify that which stage of labor is she in?

Transition: The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.

A nurse is providing discharge teaching to a client who is postpartum. For which of the following clinical manifestations should the nurse instruct the client to monitor and report to the provider?

Unilateral breast pain Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider.

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?

Vaginal Pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.

A nurse is teaching the client about effective breastfeeding who is 3 days postpartum. Which of the following should the nurse include?

Your newborn should appear content after feeding The nurse should inform the client that a baby who is sated will appear content after feedings. A baby who continues to show indications of hunger (for example, rooting, sucking on the hands, or crying) might not be effectively emptying the breasts during feeding