ATI 2023 Maternal Newborn Test A and B

For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process. PID + C-Reactive protein The nurse should expect prescription of Ceftriaxone and Doxycycline - Strong Anti-Biotics. Rest are Anti-fungal or Anti-Virals. Provide patient education and provide Ceftriaxone NOW.

Abdominal Pain - GONORRHEA. Greenish Discharge - Trichomoniasis and Gonorrhea. Diabetes - Candidias - Diabetes predisposes patients to yeast infections. Pain on urination - Trichomoniasis, Gonorrhea, and Candidiasis. Absence of Condom Use - Trichomoniasis and Gonorrhea

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test for which of the following diagnostic test should the nurse prepare the client?

Biophysical Profile (BPP) - This will help assess fetal well being.

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

Blurred vision

Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min Maternal history of methadone use during pregnancy. Which should the Nurse report? Respiratory findings Temperature Oxygen saturation Central nervous system findings Gastrointestinal findings

Gastrointestinal findings Central nervous system findings

A nurse is teaching a postpartum client about the steps the nurses will take to promote the security and safety of the clients newborn which of the following statement should the nurse make?

Staff members who take care of your baby will be wearing a photo identification badge.

When a patient is receiving a continuous infusion of magnesium sulfate IV which action should the nurse take?

Have calcium gluconate readily available.

A nurse is caring for a newborn.Medical History 1600:Apgar Score 9 at 1 min and 9 at 5 min Birth weight 10 lb 6 oz (4706 gm) Gestational age 40 weeks Difficult vaginal birth with shoulder dystocia.

Indicated: Educate the parents to begin ROM exercises on the affected arm after 1 week. - ROM help restore functionality. Delay 1 week to prevent additional injury to brachial plexus. Assess for grasp reflex in the affected extremity. - With Erb's Palsy (Erb-Duchenne) only the upper arm is affected. Wrist and finger function should NOT be affected. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. - This will assist int he healing process.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation which of the following findings should the nurse report to the provider is a potential complication?

Leakage from the vagina

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider which of the following manifestation should the nurse include? Shortness of breath when climbing stairs - NO - This is to be expected as the larger uterus will interfere with the expansion of the diaphragm and is expected. Swelling of feet/ankles at the end of the day. NO - To be expected. Headache that is unrelieved by analgesia - YES - This is a sign of preeclampsia and SHOULD be reported. Braxton Hicks contractions - These are "false" contractions that indicate the uterus is preparing for labor and is expected at 35 weeks.

Headache that is unrelieved by analgesia

Caring for a patient at the end of their first trimester, where should the nurse place the Doppler Ultrasound stethoscope in what location?

Just above the symphysis pubis. At the end of the first trimester of pregnancy the client's uterus is about the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?

Left Lower Quadrant

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

Reports increased urinary output. Will also potentially have nausea, vomitting, abdominal pain, constipation, drowsiness, and headaches. Fruity breath odor, positive sugar/acetone in urine, and high blood glucose.

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 within 72 hours following unprotected sexual intercourse.

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?

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

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?

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

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

"I will have blood tests because my potassium might decrease." - Adverse effects of terbutaline are hypokalemia + hypotension + hyperglycemia. Given every 4 hr SC but not longer than 24 hr.

A nurse on a antepartum unit is caring for four clients which of the following client to the nurse identify as a priority? A client at 34 weeks of gestation and reports epigatric pain - this patient is exhibiting signs of preeclampsia and indicates hepatic involvement.

A client at 34 weeks of gestation and reports epigatric pain

A nurse in a clinic is caring for a 16-year-old adolescent.History and PhysicalAdolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus. Which should the Nurse report?

Abdominal assessment - The pain is NOT an expected finding in a normal, healthy 16 yo. Vaginal Discharge - Greenish discharge indicates an infection. Temperature - Febrile, thus indication of infection or inflammation. Dyspaerunia - Painful intercourse or urination can be associated with STI's. Condom Usage - Sexual activity without condoms increases the risk of contracting STI's.

A nurse is caring for a client who is in labor and reports increasing rectal pressure she's experiencing contractions 2 to 3 minutes apart each lasting 80 to 90 seconds in a vaginal examination reveals in her cervix is dilated to 9 cm the nurse should identify that the client is in which of the following phases of labor? Passive descent - The CALM and REST phase. Active - Characterized by cervical dilation between 6-10cm, contractions every 1.5-5m, and lasting 40-90 seconds. Early - 0-5cm, contractions every 2-30min, lasting 30-40 seconds. Descent - Active pushing phase - 1-2 min per contractions lasting 90 seconds.

Active

A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next?

Administer oxygen via a nonrebreather mask - REMEMBER the ABC's - all the other choices are correct, but priority is A!

A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke", which of the following is the priority intervention for the nurse to take?

Begin FHR Monitoring - The greatest risk to the client and their fetus following a rupture of membranes is an umbilical cord prolapse. FHR is the PRIORITY action.

A nurse is assessing a client who gave birth vaginally 12 hours ago and palpate her uterus to the right above the umbilicus. Which of the following intervention should the nurse perform? Reassess in 2 hours? NO, you should be assessing more frequently. Administer Simethicone? NO - This med is for gassiness. Assist the client to empty their bladder? YES - The findings indicate the client's bladder is distended. This can prevent the uterus from contracting and can result in postpartum hemorrhage. Lie on their right side. No. This will do nothing to resolve the displaced uterus.

Assist the client to empty their bladder.

A nurse in a family planning clinic is caring for a client who request an oral contraceptive. Which of the following findings in the clients history show the nurse recognized as a contraindication to oral contraceptives. select all that apply Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder

Cholecystitis Hypertension Anxiety disorder

A nurse is assessing a newborn following circumcision which of the following findings should the nurse identify as an indication of the newborn is experiencing pain? Chin quivering - Could also be grimacing, brow furrowing.

Chin quivering

Client reports a small amount of bright red blood in their underwear upon awakening. Client denies contractions or abdominal pain. External fetal monitor applied. Potential Nursing Action Indicated or Contraindicated Assess cervical dilation Weigh perineal pads. Administer methotrexate. Insert a large bore intravenous catheter.

Contraindicated Assess Cervical Dilation - She's currently bleeding and not in the middle of labor, unnecessary. Administer Methotrexate - She isn't having an ectopic pregnancy - this is used to resolve ectopic pregnancies in the first trimester. Indicated Weigh Perineal Pads - We need to know how much blood she's losing. Insert a large bore IV - Third Trimester Bleeding may lead to larger hemorrhage - having IV access is critical if we need to administer fluids.

A nurse on the postpartum unit is caring for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following assessment findings should the nurse expect to find? ITP is an autoimmune response that results in a decreased platelet count. Increased Erythrocyte Sedimentation Rate - This is a sign of CHRONIC RENAL FAILURE. Decreased Megakaryocytes - Not a sign of ITP. Increased WBC - Not a sign of ITP, this is a sign of infection.

Decreased platelet count

A nurse in the antepartum clinic is assessing a client adaptation of pregnancy the client states that she is happy one minute and crying the next the nurse should interpret the clients statement as an indication of which of the following? Emotional Labilty - Rapid and unpredictable changes in mood. Couvade Syndrome - Pregnancy-Like Symptoms experienced by the father such as nausea, weight gain, etc.

Emotional Lability

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

Demonstrate to the client how to perform a newborn bath. During the "taking-hold" phase they become more focused on becoming a parent and learning new skills.

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? BELOW ARE ALL SIGNS Depression, weight gain, nausea, amenorrhea, breast tenderness, breakthrough bleeding.

Depression

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta which of the following actions should the nurse take first. ABC's!

Determine Respiratory Function

A nurse is preparing to administer oxytocin to a client who is post partum which of the following findings as an indication for the administration of the medication? Flaccid Uterus - YES - Oxytocin increases contractions and is helpful in preventing PPH. Cervical Laceration - NO - This will continue even with a contracted uterus. A surgical repair will be needed. Excessive vaginal bleeding - YES - Enhanced uterine contractions will decrease vaginal bleeding. Increased afterbirth cramping - NO - This will INCREASE cramping rather than decrease it. Increased maternal temperature is incorrect - it has nothing to do w/ temps.

Flaccid Uterus Excessive vaginal bleeding

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks gestation. Upon reviewing the clients medical record, what findings should the nurse report to the provider? 1-hr Glucose of 130 to 140 (or greater) indicates a positive test. Hematocrit of 34% is within range - should be greater than 33%. FHR - Should be between 110/min to 160/min for a client at 26 weeks of gestation.

Fundal height 30 cm - Fundal height should be PLUS or MINUS 2cm from weeks of gestation

A nurse is reviewing the laboratory results for a client who is at 10 weeks gestation which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10g/dL YES - this is below the 11 g/dL minimum for pregnant women. WBC Count - 15,000 - NO - normal is 5-15k during pregnancy RBC 5.8million/mm3 - NO Within range of 5-6.25million for pregnancy. Hematocrit 34% - NO - greater than 33% is fine.

Hemoglobin 10g/dL

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

Hypertension - It's a vasoconstrictor that can cause hypertension but will also prevent bleeding out.

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? I should increase my protein intake to 60 grams each day. NO - Should be a minimum of 71g each day. I should drink 2 liters of water each day. NO - A client who is pregnant should consume 3 liters of water each day. I should increase my overall caloric intake by 300 calories. NO - It should be 340 calories their first trimester, 452 during third trimester. I should take 600 micrograms of folic acid each day. YES - Folic acid is CRITICAL for preventing neural tube birth defects.

I should take 600 micrograms of folic acid each day.

A nurse is providing dietary teaching to a client who has hyper emesis gravidarum which of the following statements by the client indicates understanding of the teaching? Eat foods that taste food instead of balancing my meals. YES - The focus should be avoiding nausea. I will avoid having a snack before bed. NO - Clients should avoid going to bed with an empty stomach. Instruct them to eat a healthy snack (that they enjoy!) before bed. I will have a cup of hot tea with each meal. NO - They should ALTERNATE solids and liquids every 2-3 hours to avoid an empty stomach AND avoid OVERFILLING. I will eliminate products that contain dairy from my diet. NO - They should be encouraged to consume dairy as these are less likely to cause nausea.

I will eat foods that taste good instead of balancing my meals.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following should the nurse include in the plan of care? Maintain NPO throughout procedure? NO - Clients are often encourage to drink liquids to promote adequate hydration. Place the client in a supine position? NO - They should be in a SITTING position or a Semi-Fowlers position and TILTED to promote uterine perfusion. Instruct the client to massage the abdomen to stimulate fetal movement? NO - This doesn't do anything for fetal movement. Instruct the client to press the provided button EACH time fetal movement is detected. YES The FHR might miss movements but by pressing the button it will record it.

Instruct the client to press the provided button EACH time fetal movement is detected.

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

Kleihauer-Betke test - This will determine if fetal blood is in maternal circulation.

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 requires notification of the provider? Late Decels - Indication of uteroplacental insufficiency. Do NOT give Oxytocin if these are present. Moderate Variability - This expected - not a contraindication to Oxytocin. Cessation of Uterine Dilation - This is an INDICATION to use Oxytocin. Prolonged active phase of labor - an INDICATION to use Oxytocin to augment their labor.

Late Decelerations

A nurse is assessing a newborn who was born at 26 weeks gestation. Using the New Ballard Score which of the following findings should the nurse expect? Minimal arm recoil - Nurse should expect newborn to have HYPOTONIA or minimal arm recoil. Popliteal angle of 90 degrees - Sign of MATURITY in a newborn, expected after 26 weeks. Creases over the entire foot - Signs of maturity increasing over the term of a fetus. Raised aureoles with 3 to 4 mm buds - Sign of maturity.

Minimal arm recoil - Nurse should expect newborn to have HYPOTONIA or minimal arm recoil.

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? Check the client's temperature- You do monitor for an infection post amniocentesis but FIRST do FHR. Observe the uterine contractions- Yes - but FIRST do FHR. Administer Rho(D) immune globulin- You WILL do this, but FIRST start FHR. Monitor the FHR - The greatest risk of an amniocentesis is the death of the fetus.

Monitor the FHR

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.

A nurse is reviewing the medical record for a newly admitted client who is 32 weeks gestation. Which of the following conditions is an indication for fetal heart rate monitoring? Oligohydramnois - YES - Along with other things such as preeclampsia, IUG Restriction, Renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, SLE (Lupus), intrahepatic cholestasis. Hyperemesis Gravidarum - Nope. Leukorrhea - White-ish discharge is common during pregnancy. Periodic Tingling - Common occurrence during pregnancy.

Oligohydramnois

A nurse is preparing to perform Leopold's Maneuvers for a client identify the sequence the nurse should follow?

Palpate the funds to identify the fetal partDetermine the location of the fetal backPalpate for the fetal part presenting at the inletIdentify the altitude of the head

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? Administer Penicillin g2.4 million units - No, this should be done for syphilis. Instruct Client to schedule annual pelvic examination - NO - should be every 6 months. Tell the client they'll start medication for HIV immediately after delivery. NO - It will begin DURING the prenatal AND perinatal periods to decrease the risk of transmission to the newborn. Report the client's condition to the local health department. YES - HIV is one of the conditions that is REQUIRED to be reported.

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

A Nurse is assessing a late preterm newborn. Which of the following mainfestations is an indication of hypoglycemia? Hypertonia - NO - HYPOtonia. Increased Feedings - NO - Low blood sugar newborns will exhibit POOR feeding behaviors. Hyperthermia - NO - They will have HYPOthermia. Respiratory Distress - YES - Alongside jitteriness, lethargy, poor feeding, apnea, seizures, and an abnormal cry.

Respiratory distress.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). What action should the nurse take ?

Schedule an ultrasound examination - this is done to detect possible development of fetal hydrops.

A nurse is assessing a 16 hr old newborn. Which of the findings should the nurse report to the provider? Substernal Retractions - This, alongside apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection OR respiratory distress in newborns and should be reported IMMEDIATELY. Acrocyanosis - Expected finding for the first 24 hours of birth, this is the blueish hue/tinge to extremities. Overlapping Suture Lines - This is an expected finding. Head Circumference - 33cm/13in. - WITHIN RANGE

Substernal Retractions

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit which of the following findings should the nurse report to the provider? Swelling of the face - YES - Signs of preeclampsia include swelling of the face, sacral area, and fingers. Varicose Veins in the calves - Expected finding. Nonpitting 1+ ankle edema - Expected finding int he third trimester. Hyperpigmentation of the cheeks, areola, vulva, and linea nigra - Expected findings.

Swelling of the face

A nurse is planning care for a client who is in labor and is to have an amniotomy which of the following assessments for the nurse identify as a priority? TEMPERATURE - The GREATEST risk of an amniotomy is INFECTION.

Temperature

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

Unilateral Breast Pain - Could be a sign of mastitis.

A nurse is caring for a newborn who was transferred to the nursery 30 minutes after birth because of mild respiratory distress which of the following actions should the nurse take FIRST? Confirm Apgar Score - NO - This is done at 1 min and again at 5 min - It should be confirmed but FIRST... Verify the newborns identification - YES - always verify the band! Administer Vitamin K - This should be done ASAP but can be delayed, before doing anything the Nurse should verify the baby they're working on. Determine Obstetrical Risk Factors - Not FIRST, this is done after confirming baby's ID.

Verify the newborns identification

A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Vomiting - Also could be irritability, agitation, tremors, or diarrhea. These manifestations typically last 2 days.

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? A) administer aspirin for pain B) maintain the client on bed rest - Lowers the risk of dislodging the clot. C) massage the affected leg every 12hr D) apply cold compresses to the affected calf

maintain the client on bed rest