Maternal newborn ATI test A

A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?

BUN 25 mg/dl

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

Massage the client's fundus.

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?

Cold cabbage leaves

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?

Petechiae over the head

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

A client who is at 11 weeks of gestation and reports abdominal cramping

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?

Pregestational diabetes mellitus

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which or the following finding! Should the nurse identify as a risk factor for the development of preeclampsia?

Report of decreased fetal movement

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?

Fundal heignt measurement

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Begin FHR monitoring.

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority?

Abruptio placenta

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?

Reports increased urinary output

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

Blurred vision

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?

Vaginal pressure

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?

Report of visual disturbances

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Weight gain of 2.2 kg (4.8 Ib)

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report tothe provider?

Naloxone

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer?

Hypertension

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

Respiratory distress

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

jaundice

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

Substernal retractions

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

Minimal arm recoil

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?

A reduction in respiratory distress in the newborn

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?

Monitor the FHR.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Report the client's condition to the local health department.

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?

Kleihauer-Betke test

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?

Administer oxygen via a nonrebreather mask.

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure?

Respiratory rate 10/min

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?

Premature rupture of membranes

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?

Have the client change position.

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?

Biophysical profile

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests?

To locate a pocket of fluid

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?

Perform Leopold maneuvers.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

Calcium gluconate

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity?

late decelerations

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?

Maintain the client on bed rest.

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?

Schedule an ultrasound examination.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?

Protect the client's head and feet from cold air.

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?

Monitor the FHR continuously.

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Remove all clothing from the newborn except the diaper.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?

Lays the newborn across her lap and gently sways

A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?

Acrocyanosis, Positive Babinski reflex, Two umbilical arteries visible

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.)

FHR 152/ min

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part

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?

Place the newborn skin to skin on the mother's chest.

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?

"You can still become pregnant if you are breastfeeding.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?

Obtain a gift from the newborn to present to the sibling.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?

The person who comes to take my baby's pictures will be wearing a photo identification badge."

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?

Depression

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?

will likely need to use alternative positions for sexual intercourse."

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

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

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?

hemoglobin of >10g/dL

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider?

"I should take 600 micrograms of folic acid each day."

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"You should press the handheld button when you feel your baby move.

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?

"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen."

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?

Verify that the parent's identification band matches the newborn's identification band.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.)

Heart rate 154/min Respiratory rate 58/min Weight 2,600 g (5 lb 12 oz)

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Wipe the newborn's eves from the inner canthus outward Wash the newborn's neck by lifting the newborn's chin. Cleanse the skin around the newborn's umbilical cord stump. Wasn the newborn's legs and reet. Clean the newborn's diaper area.