Maternity ATI practice questions Exam 4
A nurse is reinforcing teaching about phenylketonuria (PKU) testing with the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? A. "My baby will be placed under special lights if the test is elevated." B. "My baby must take formula or breast milk before the test is done." C. "This test checks for a genetic disorder that can be corrected by diet." D. "Sometimes the test is repeated in the doctor's office at the 2-week check-up."
A. "My baby will be placed under special lights if the test is elevated." Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn.
A nurse is caring for a hospitalized 2-month-old infant whose mother brings in expressed breast milk. The infant takes 2 oz of breast milk at 0800, 3 oz at 1100, and 2.5 oz at 1300. Which of the following should the nurse record as the client's intake for the shift? A. 225 mL B. 150 mL C. 240 mL D. 375 mL
A. 225 mL Multiply the total ounces by 30 mL per oz: 7.5 x 30 = 225 mL
A nurse is collecting data from a client who has just had a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen? A. At the level of the umbilicus B. Three finger breadths above the umbilicus C. One finger breadth above the symphysis pubis D. To the right of the umbilicus
A. At the level of the umbilicus Within 12 hr., the fundus should rise just about to the level of the umbilicus and then recede 1 to 2 cm each day.
A nurse places the newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress B. Shivering C. Thermogenesis D. Brown fat production
A. Cold stress Prevention of cold stress is important to decrease metabolic and physiologic demands on the newborn.
A nurse is preparing to administer RHO (D) immunoglobulin (RhoGAM). An Rh incompatibility can lead to which of the following? A. Hydrops fetalis B. Hypobilirubinemia C. Congenital hypothermia D. Transient clotting difficulties
A. Hydrops fetalis Hydrops fetalis results from an Rh incompatibility.
A nurse is caring for a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. The nurse is aware that respiratory acidosis is caused by which of the following? A. Inadequate chest expansion B. Retention of oxygen C. Increased alveolar-capillary diffusion. D. Reduced production of free hydrogen ions
A. Inadequate chest expansion Inadequate chest expansion leads to retention of carbon dioxide, which is the cause of respiratory acidosis.
A nurse is planning care for an infant that has been diagnosed with phenylketonuria (PKU). Which of the following is an appropriate action for the nurse to take? A. Initiate a controlled diet eliminating protein. B. Educate parents on blood glucose monitoring. C. Administer thyroid hormone replacement. D. Obtain a blood sample for blood type.
A. Initiate a controlled diet eliminating protein. PKU is managed by eliminating phenylalanine from the diet. All natural food proteins contain phenylalanine. Therefore, initiating a controlled diet eliminating protein is the appropriate action for the nurse to take.
A nursery nurse is admitting a term newborn following a cesarean birth. The nurse observes that the infant's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility B. Absence of vitamin K C. Physiologic jaundice D. Maternal cocaine abuse
A. Maternal/newborn blood group incompatibility Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice, and the jaundice appears within the first 24 hr. of life.
A nurse is admitting a client to the postpartum unit who experienced a vaginal birth 2 hr. earlier. The client has an IV of lactated Ringers with 25 units of oxytocin infusing and large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respirations 18/min. The nurse reviews the prescriptions by the provider. Which of the following prescriptions requires clarification? A. Methylergonovine (Methergine) 0.2 mg IM now. B. Insert an indwelling urinary catheter. C. Administer oxygen by non-rebreather mask at 5L/min. D. Obtain laboratory study of prothrombin and partial thromboplastin time.
A. Methylergonovine (Methergine) 0.2 mg IM now. Methergine is contraindicated in the client with a blood pressure greater than 140/90. This prescription requires clarification.
A nurse is reinforcing teaching to the mother of an infant born small for gestational age. Which of the following should the nurse include as a cause of this condition? A. Placental insufficiency B. Maternal obesity C. Primipara D. Perinatal asphyxia
A. Placental insufficiency Placental insufficiency is a cause of small for gestational age. It may result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.
A nurse is caring for a client who is to receive RhoGAM injections. When reinforcing teaching with this client, the nurse explains that the action of Rho(D) immune globulin (RhIG or RhoGAM) is to: A. Prevent the formation of Rh antibodies by a woman who is Rh-negative. B. Destroy Rh antibodies in a woman who is Rh-negative. C. Destroy Rh antibodies in a newborn who is Rh-positive. D. Prevent the formation of the RH antibodies in a newborn who is Rh-positive.
A. Prevent the formation of Rh antibodies by a woman who is Rh-negative. Giving RhoGAM prevents the client's immune system from forming antibodies secondary to exposure to fetal blood during pregnancy or delivery.
A client has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. Hyperbilirubinemia occurs with Rh incompatibility between client and fetus because: A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The clients blood contains the Rh factor, and the newborns does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of previous jaundice caused by a blood transfusion, affecting the fetus through the placenta. D. The newborn develops a congenital defect shortly after birth that causes the destruction of red blood cells.
A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. Rh antigens from the fetus enter the bloodstream of the client, causing the production of anti-Rh antibodies in the client. These anti-Rh antibodies cross the placenta, enter the fetal circulation, and cause hemolysis. The red blood cells break down faster than the body can excrete the products of hemolysis, including bilirubin. Serum bilirubin rises quickly.
A nurse is caring for a client who is 32 weeks of gestation who has hyperthyroidism. For which of the following clinical findings should the nurse monitor and report to the provider? (Select all that apply) A. Fever B. Tachycardia C. Vomiting D. Hypertension E. Restlessness
ABCE Fever Tachycardia Vomiting Restlessness
A client at 40 weeks of gestation is about to undergo a biophysical profile. The nurse should explain that this profile focuses on which of the following parameters? (Select all that apply.) A. Fetal breathing B. Fetal motion C. Nuchal translucency D. Amniotic fluid volume E. Fetal gender
ABD
A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. Incomplete abortion is the initial diagnosis. Which of the following actions should the nurse contribute to the clients plan of care? A. Prepare to administer oxygen. B. Determine the amount and type of vaginal bleeding. C. Instruct the client in appropriate birth control methods. D. Keep the client on bed rest.
B. Determine the amount and type of vaginal bleeding. Bleeding may continue until the client has expelled all of the products of conception. It is important for the nurse to note the amount and type of bleeding and to monitor the client for indications of excessive blood loss.
A nurse is caring for an infant who has hydrocephalus. Which of the following manifestations should the nurse expect to find? A. Proteinuria B. Dilated scalp veins C. Hypertension D. Pulsatile fontanels
B. Dilated scalp veins Manifestations of hydrocephalus in infancy include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.
A nurse on the postpartum unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse recognizes this client is at risk for which of the following postpartum complications? A. Amniotic fluid embolism B. Disseminated intravascular coagulation C. Preeclampsia D. Puerperal infection
B. Disseminated intravascular coagulation Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.
A nurse is reinforcing teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding? A. I will place my baby on his stomach when he is sleeping. B. I will warm the crib sheets before putting my baby to bed. C. I should place the crib near a window to provide adequate sunlight and fresh air. D. I should place my baby's stuffed animals between the mattress and side of the crib.
B. I will warm the crib sheets before putting my baby to bed. Prewarming crib sheets is an acceptable infant quieting technique. The sheets can be prewarmed with a hot water bottle or heating pad that should be removed before putting the baby to bed. Some babies startle and awaken when placed on a cold sheet.
A nurse is caring for a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSAFP) determination. The nurse should reinforce with the client that this test screens for A. Gestational diabetes. B. Neural tube defects. C. Fetal maturity. D. ABO incompatibility
B. Neural tube defects. MSAFP measures blood levels of alpha-fetoprotein in the client's blood. Abnormal levels can indicate a neural tube defect such as spina bifida, as well as multifetal pregnancies and fetal abdominal wall defects.
A nurse is caring for a client who is pregnant and has iron-deficiency anemia. To enhance the client's iron absorption, which of the following beverages should the nurse recommend? A. Milk B. Orange juice C. Tea D. Hot chocolate
B. Orange juice Orange juice and other vitamin C-rich foods and beverages enhance iron absorption. Tea interferes with iron absorption. Chocolate interferes with iron absorption.
A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for postpartal hemorrhage due to uterine atony because she had a A. Midline episiotomy B. Precipitous delivery C. Vaginal delivery D. Periurethral tear
B. Precipitous delivery The risk of uterine atony increases whenever the uterus has been overstressed or overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr.).
A nurse working on a postpartum unit is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply). A. Polyuria B. Dysuria C. Costovertebral angle tenderness D. Urinary frequency E. Hematuria
BCDE
A nurse is caring for several newborn clients. The nurse needs to notify the charge nurse after observing: A. A blood glucose fingerstick of 60 mg/dL in an infant who is 1 hr. old. B. Acrocyanosis in an infant who is 2 hr. old. C. Jaundice in an infant who is 4 hr. old. D. A hematocrit of 45% in an infant who is 8 hr. old.
C. Jaundice in an infant who is 4 hr. old. Jaundice occurring within the first 24 hr. of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately.
A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative, and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an: A. "It determines if kernicterus will occur in the newborn." B. "It detects Rh negative antibodies in the newborns blood." C. "It detects Rh positive antibodies in the mother's blood." D. "It determines the presence of maternal antibodies in the newborns blood."
C. "It detects Rh positive antibodies in the mother's blood." An indirect Coombs test is performed on the mother's blood to determine if she has developed antibodies to the Rh antigen.
A nurse caring for a client who is in labor is reinforcing teaching about why epidural anesthesia is not initiated until a good labor pattern has been established. The nurse should tell the client, "Given too soon, epidural anesthesia: A. "Can cause fetal depression." B. "Will delay rupture of fetal membranes." C. "May prolong labor." D. "May cause maternal hypertension."
C. "May prolong labor." Progress in labor slows when clients are given anesthesia before the active phase of labor. The medication depresses the central nervous system; thus, it will take longer for the cervix to dilate and efface.
A client is admitted to the maternity who is 38 weeks' gestation and experiencing polyhydramnios. The nurse understands that this diagnosis means that: A. There is the normal amount of amniotic fluid, thinner in volume. B. A less-than-normal amount of amniotic fluid is present. C. An excessive amount of amniotic fluid is present. D. A leak is causing fluid to accumulate outside the amniotic sac.
C. An excessive amount of amniotic fluid is present. The nurse understands an excessive amount of amniotic fluid is present greater than 1000mL, and may occur in mothers with diabetes or eclampsia.
A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. The client tells the nurse that the provider said he cannot examine her internally and the client asks the nurse why. The nurse should explain that this is primarily because an internal examination could: A. Introduce infection. B. Initiate preterm labor. C. Cause profound bleeding. D. Rupture the fetal membranes.
C. Cause profound bleeding. Pelvic rest is essential for clients who have placenta previa. This means no vaginal examinations, no douching, and no vaginal intercourse. This is because any pressure on the placenta could cause its premature separation and life-threatening hemorrhage.
A nurse is collecting data from a client who is postpartum, 2 hr. following delivery of a healthy newborn. Which of the following findings indicates the client's bladder is distended? A. Increased uterine contractions. B. Decreased lochia. C. Elevated fundus level D. Pulse 52/min
C. Elevated fundus level If the bladder is distended, it will push the uterus up out of the pelvis above the umbilicus, thus elevating the level of the fundus.
A nurse is collecting data on a newborn that is 48 hr. old. Which of the following findings should the nurse report to the provider? A. Telangiectatic nevi B. Erythema toxicum C. Generalized petechiae. D. Mongolian spot
C. Generalized petechiae. Generalized petechiae may indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation. Mongolian spots are bluish black areas which commonly appear over the back or buttocks. They are frequently seen in Latin America, African, or Asian newborns. This finding has no clinical significance.
A client delivered a 34-week, 1,550-g newborn who has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral thermal environment because: A. He has a small body surface for his weight. B. Heat increases flow of oxygen to his extremities. C. His temperature control mechanism is immature. D. Heat facilitates the drainage of mucus.
C. His temperature control mechanism is immature. Preterm newborns have poor body control of temperature and needs immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity. They require an external heat source that regulates their immediate environment via a sensor attached to the skin.
A nurse in a clinic is caring for a group of clients who are pregnant and reviewing their medical records. The nurse anticipates the provider will order an amniotic fluid alpha-fetoprotein screening for which of the following clients? A. Has mitral valve insufficiency B. Has been exposed to AIDS C. History of having delivered a child with a neural tube defect D. History of preterm labor
C. History of having delivered a child with a neural tube defect Screening for alpha-fetoprotein is indicated for the client who previously delivered a child with a neural tube defect.
A nurse is reinforcing teaching to a parent about initiating an iron fortified formula to her 4-month-old infant. Which of the following should be included in the teaching? A. Iron will facilitate eyesight development. B. Iron will facilitate bone growth. C. Infants iron source starts to deplete. D. Infants do not metabolize iron adequately.
C. Infants iron source starts to deplete. Iron sources deplete and need to be supplemented in infants.
A nurse is observing a client for signs of postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? A. Dark red lochia B. Bradycardia C. Pelvic pain D. Hematuria
C. Pelvic pain Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.
A nurse is assisting with the care of a client who is at 38 weeks of gestation, in early labor with membranes intact, and has an oral temperature of 38.9 C (102F). Besides notifying the provider, which of the following is an appropriate nursing action? A. Recheck the client's temperature in 4 hr. B. Administer acetaminophen (Tylenol). C. Prepare to suppress uterine activity. D. Prepare the client for membrane rupture.
C. Prepare to suppress uterine activity. The nurse cannot determine the course of action until the provider determines the probable cause of the temperature elevation. For example, if the client has chorioamnionitis, dysfunctional labor is likely, and the provider might advise cesarean delivery.
A nurse is caring a client who is 1 day postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis? A. Swelling in both breasts B. Cracked and bleeding nipples. C. Red and painful area in one breast D. Temperature of 38 100
C. Red and painful area in one breast Mastitis often appears as a red, hard, and painful area. Although mastitis may occur in both breasts, it is usually unilateral. After delivery, the nurse should monitor a woman's breasts for signs of mastitis and reinforce instruction for breast self- examination.
A client who is at 22 weeks of gestation has been unable to control her gestational diabetes with diet and exercise. The nurse should explain to the client that it is likely that the provider will prescribe which of the following medications to control her blood glucose levels? A. Acarbose (Precose) B. Repaglinide (Prandin) C. Regular insulin (Humulin R) D. Glipizide (Glucotrol)
C. Regular insulin (Humulin R) Insulin is the drug of choice for gestational diabetes. Insulin lowers blood glucose levels without harming the fetus. With the exception of glyburide (DiaBeta), women who are pregnant do not take oral hypoglycemics because they cross the placenta and can injure the fetus.
A nurse is talking with a client who is at 15 weeks of gestation and is about to undergo an amniocentesis. The nurse should reinforce that this test can identify which of the following traits or problems? (Select all that apply.) A. Rh incompatibility B. Cephalopelvic disproportion C. Chromosome defects D. Neural tube defects E. Fetal gender
CDE Chromosome defects Neural tube defects Fetal gender
A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately? A. A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful. B. A client who is at 28 weeks of gestation and receiving terbutaline (Brethine) reports fine tremors. C. A client who has a diagnosis of preeclampsia has 2+ patellar reflexes and 2+ proteinuria. D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache.
D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache. These symptoms indicate that the client's condition is worsening and are symptoms of severe preeclampsia. Signs and symptoms of severe preeclampsia include the following: Blood pressure of 160/100 mm Hg or greater. Proteinuria 3 to 4+ Oliguria Elevated serum creatinine greater than 1.2 mg/dL Cerebral or visual disturbances (headache and blurred vision) Hyperreflexia with possible ankle clonus Pulmonary, cardiac, or hepatic involvement including elevated liver enzymes, nausea, vomiting, epigastric pain, and right upper-quadrant pain Extensive peripheral edema Thrombocytopenia.
A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta previa B. Prolapsed cord C. Ruptured ovarian cysts D. Abruptio placentae
D. Abruptio placentae The cardinal signs and symptoms of abruptio placentae include a rigid board-like abdomen, severe pain, and heavy vaginal bleeding.
A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe pre- eclampsia. When collecting data from the client, the nurse should expect which of the following findings? A. Tachycardia B. Diplopia C. Polyuria D. Headache
D. Headache Severe pre-eclampsia does not cause tachycardia, but it does cause hypertension. Severe pre-eclampsia is more likely to cause blurred vision and photophobia than diplopia. Severe pre-eclampsia causes proteinuria and oliguria, not polyuria. Severe pre-eclampsia causes headache, blurred vision, irritability, nausea, vomiting, hypertension, proteinuria, and edema.
A nurse in a prenatal clinic is caring for a client at 12 weeks' gestation. The client asks about the cause of her heartburn. Which of the following is the appropriate response by the nurse? A. Increased pancreatic activity results in intolerance of fats in the diet. B. Increased estrogen production causes increased secretion of hydrochloric acid. C. Pressure from the growing uterus displaces the stomach. D. Increased progesterone production causes decreased motility of smooth muscle.
D. Increased progesterone production causes decreased motility of smooth muscle. Increased progesterone production causes a relaxation of the cardiac sphincter and delayed gastric emptying which can result in heartburn.
A nurse is caring for a neonate who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which nursing goal has the highest priority in the care of this infant? A. Provide age-appropriate stimulation. B. Promote maternal-infant bonding. C. Educate the parents about the defect. D. Maintain integrity of the sac.
D. Maintain integrity of the sac. The greatest risk to this client is injury from damage to the exposed spinal cord and fluid filled sac; therefore, the priority intervention is to maintain the integrity of the sac.
A nurse is caring for a client in the prenatal clinic with a possible ectopic pregnancy at 8 weeks of gestation. Which of the following is an expected finding for this client? A. Uterine enlargement greater than expected for gestational age B. Copious vaginal bleeding C. Severe nausea and vomiting D. Pelvic pain
D. Pelvic pain Pelvic pain is an early sign of ectopic pregnancy.
A client in labor at 40 weeks of gestation reports that she has saturated two perineal pads in the past 30 min. The nurse assisting with her care suspects placenta previa. For which of the following actions should she prepare the client? A. Examination to determine cervical status B. A magnesium sulfate infusion C. Initiation of pushing D. Preparation for cesarean birth
D. Preparation for cesarean birth Placenta previa is an indication for cesarean birth.
A nurse in a provider's office is reinforcing teaching for a client with mild pre-eclampsia. Which of the following should the nurse include in the teaching? A. Rest in bed in the supine position. B. Limit sodium intake to 1,200 mg/day. C. Limit fluid intake to 1,000 mL/day. D. Test urine once a day for protein.
D. Test urine once a day for protein. The amount of protein in the urine should be tested at least once a day. An increase in protein in the urine should be reported to the provider because it may indicate the pre-eclampsia is worsening.