ATI: Maternal Newborn Practice Assessment

A nurse is preparing to palpate the uterine fundus of a client who is at 22 weeks of gestation to measure fundal height. At which of the following locations should the nurse expect to find the fundus? A. About 3 cm above the umbilicus B. Slightly above the umbilicus C. Slightly below the umbilicus D. About 3 cm below the umbilicus

B. Slightly above the umbilicus

A nurse is caring for a client who has a suspected placenta previa. Which of the following is an appropriate nursing action? A. Complete a vaginal exam B. Perform a rectal exam C. Apply ice to the peri area D. Apply an external fetal monitor

D. Apply an external fetal monitor

A client who is postpartum and is breastfeeding her newborn tells the nurse that her nipples are sore. Which of the following interventions should the nurse suggest to the client? A. Apply a light coating of mineral oil to the nipples between feedings B. Keep the nipples covered in between breastfeeding sessions C. Increase the time between feedings until the nipples are less sore D. Change the newborn's position on the nipples with each feeding

D. Change the newborn's position on the nipples with each feeding

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? A. Chills shortly after delivery B. Fundus at umbilicus level C. Urinary output 3,000 mL per 12 hour D. Pulse rate 110 beats/minute

D. Pulse rate 110 beats/minute

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 postion 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

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if the can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse? A. "You may carry your grandchild to the room." B. "You can push the baby to the room in a wheeled bassinet." D. "If you show me your photo identification, you can take the infant."

C. "Have the mother call and I will take the baby to the room."

A nurse is caring for a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 and the fetal heart recording is 140 beats/min. Which of the following actions by the nurse is a priority? A. Elevate the legs B. Monitor vital signs every 5 min C. Call the physician immediately D. Turn the client in a lateral position

D. Turn the client in a lateral position The nurse should have the client turn laterally to relieve the pressure on the inferior vena cava and improve the blood pressure

Immediately after a cesarean delivery, a nurse is caring for a newborn who weighs 5,160 g (11 lb 6 oz) and whose mother has diabetes mellitus. The priority data collection for this newborn is for A. Hypoglycemia B. Hypomagnesemia C. Hyperbilirubinemia D. Hypocalcemia

A. Hypoglycemia

A nurse is planning care for an infant that has been diagnosed with phenylketonuria. 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

A client who is postpartum and is breastfeeding her newborn asks the nurse about dietary precautions. The client states that food allergies "run in her family." The nurse should tell the mother to avoid eating A. Peanuts B. Asparagus C. Lamb D. Blueberries

A. Peanuts

A nurse is reinforcing teaching to a class of pregnant women about fetal development. Which of the following statements should the nurse include in her teaching? A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." B. "The sex of the baby is determined by week 8 of pregnancy." C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy." D. "You will first feel your baby move by week 24 pregnancy."

A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."

A nurse is caring for a client who visits the prenatal clinic stating that she thinks she may be pregnant because she is able to feel the baby move. Which of the following statements by the nurse is an appropriate response? A. "This is a presumptive sign of pregnancy." B. "This is probable sign of pregnancy." C. "This is a possible sign of pregnancy." D. "This is a positive sign of pregnancy."

A. "This is a presumptive sign of pregnancy."

A nurse in a prenatal clinic is reviewing the record of a client at 28 weeks of gestation. The woman's history reveals one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes her present parity? A. 2-0-1-2-2 B. 1-0-2-2-2 C. 2-0-0-2-2 D. 0-2-0-2-2

A. 2-0-1-2-2 2 pregnancies that have reached 20 weeks or more of gestation (G) NO term births (T) ONE birth given in the preterm (P) TWO pregnancies ended in abortion (A) TWO living children (2)

A nurse is assisting with the care of a client who is in labor. When monitoring the uterine contractions the nurse is aware that relaxation between contractions should be greater than A. 30 seconds B. 45 seconds C. 60 seconds D. 75 seconds

A. 30 seconds

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggests to help lessen discomfort during breastfeeding? A. Apply breast milk to her nipples before each feeding B. Alternate breasts at the beginning of each feeding C. Let the newborn sleep for long periods do the nipples can heal D. Start breastfeeding with the nipple that is less sore E. Change the infant's position on the nipples

A. Apply breast milk to her nipples before each feeding B. Alternate breasts at the beginning of each feeding D. Start breastfeeding with the nipple that is less sore E. Change the infant's position on the nipples

A nurse is caring for a client who has had a dilation and curettage following a spontaneous abortion. The client tells the nurse that she is hungry. Which of the following initial actions by the nurse is appropriate? A. Auscultate the client's abdomen B. Offer clear liquids C. Ask the client if she is experiencing pain D. Check the client's chart for a diet prescription

A. Auscultate the client's abdomen

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

A nurse is caring for a client immediately after delivery. After assuring a patent airway, which action would be the nurse's priority in the care of the infant? A. Dry the infant and place him in a radiant heat warmer B. Administer Vitamin K intramuscular C. Perform a complete physical assessment and document findings D. Implement identification procedures

A. Dry the infant and place him in a radiant heat warmer

A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period? A. Expressions of excitement B. Lack of appetite C. Focuses on the family unit and its members D. Eagerness to learn newborn care skills

A. Expressions of excitement

A client at 40 weeks gestation is about to undergo a biophysical profile. The nurse should explain that this profile focuses on which of the following parameters? A. Fetal breathing B. Fetal motion C. Nuchal translucency D. Amniotic fluid volume E. Fetal gender

A. Fetal breathing B. Fetal motion D. Amniotic fluid volume

A nurse is preparing to administer RHO 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

A nurse on the postpartum unit is caring for a group of clients with the assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP? A. Provide a sitz bath to a client with a fourth-degree laceration who is 2 days postpartum B. Observe an area of redness on the breast of a client who is 1 day postpartum C. Monitor vital signs of a client being admitted with gestational hypertension D. Change the perineal pad of a client who just transferred from labor and delivery

A. Provide a sitz bath to a client with a fourth-degree laceration who is 2 days postpartum

A nurse is collecting data from an infant with Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? A. Transverse palmar creases B. Large ears C. Muscular hypertonicity D. Protruding tongue E. Low birth weight

A. Transverse palmar creases D. Protruding tongue

A nurse is preparing to administer vitamin K by intramuscular injection to a newborn. Into which of the following muscles should the nurse inject the medication? A. Vastus laterails B. Ventrogluteal C. Dorsogluteal D. Deltoid

A. Vastus laterails

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor place and IV fluid infusing. The nurse notes variable deceleration in the fetal heart rate on the monitoring strip. The nurse knows that the probable cause of this pattern is A. umbilical cord compression B. uteroplacental insufficiency C. maternal opioid administration D. fetal head compression

A. umbilical cord compression

A nurse is caring for a client during a non-stress test. The nurse observes two deceleration of 15 beats/min in the fetal heart rate during a period of fetal movement. Each deceleration lasts 20 seconds. This indicates which of the following findings? A. A negative test B. A nonreactive test C. A positive test D. A reactive test

B. A nonreactive test

A nurse in the prenatal clinic is reinforcing teaching to a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which statement by the client indicates a need for further teaching? A. "I should limit my carbohydrates to 50% of caloric intake." B. "I will reduce my exercise schedule to 3 days a week." C. "I will take my glyburide daily with breakfast." D. "I know I am at increased risk to develop type 2 diabetes."

B. "I will reduce my exercise schedule to 3 days a week."

A nurse is reinforcing teaching about contraceptives for a group of female clients. Which of the following client statements reflects appropriate knowledge regarding proper use of a diaphragm? A. "Remove the diaphragm promptly following intercourse and then douche." B. "Leave the diaphragm in for at least 6 hr after vaginal intercourse." C. "Never use creams or jellies so the diaphragm will fit snugly." D. "Insert the diaphragm at least 4 hr prior to vaginal intercourse to allow for a protective seal."

B. "Leave the diaphragm in for at least 6 hr after vaginal intercourse."

A client who has a body mass index of 26.5 has just found out that she is pregnant. She asks the nurse how much weight she should gain over the course of her pregnancy. Which of the following is the appropriate nursing response? A. "It would be best if you gained about 11 to 20 pounds." B. "The recommendation for you is about 15 to 25 pounds." C. "A gain of about 25 to 35 pounds is best for you and for your baby." D. "It really doesn't matter exactly how much weight you gain, as long as your diet is healthful."

B. "The recommendation for you is about 15 to 25 pounds."

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

A nurse on the postpartum unit is caring for a client who experienced abruptio placenta. 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

A nurse is assisting a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A. Moderate lochia rubra B. Fundus three finger breaths above the umbilicus C. Moderate swelling of the labia D. Blood pressure 130/84 mm Hg

B. Fundus three finger breaths above the umbilicus

A nurse in a provider's office is reinforcing teaching to a client who is 34 weeks of gestation and at risk for placenta abruption. The nurse recognizes that which of the following is the most common risk factor for abruption? A. Maternal cocaine use B. Maternal hypertension C. Maternal battering D. Maternal cigarette smoking

B. Maternal hypertension

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

A nurse is reinforcing teaching to a group of postpartum clients about nutritional requirements during lactation. The nurse recommends increased intake of which of the following nutrients? A. Calcium B. Zinc C. Folic acid D. Iron

B. Zinc

A nurse is assisting a newborn the day after delivery. The nurse notes a raised bruised area on the left side of the scalp that does not cross the suture line. The nurse should document this findings as A. caput succedaneum B. cephalhematoma C. molding D. cradle cap

B. cephalhematoma Swelling of the subcutaneous tissue of the newborn's scalp with blood

A nurse is speaking to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following is an appropriate response by the nurse? A. "Come to the office and we sill check things out." B. "Go to the emergency room and your provider will meet you there." C. "This expected because of the way iron is broken down during digestion." D. "What else have you been eating?"

C. "This expected because of the way iron is broken down during digestion."

A nurse performing a non-stress test for a pregnant client. After 20 min, the client reported having felt four fetal movements. The nurse notes that each fetal movements was accompanied by an increase in the fetal heart rate of 10 to 15 beats per minute lasting approximately 15 to 20 seconds before returning to the baseline FHR of 130 to 136 beats per minute. The nurse interprets the results as indicating which of the following? A. Impaired perfusion of the placenta B. Neurological immaturity of the fetus C. A health fetal response to activity D. Poor response of the fetus to movement

C. A health fetal response to activity

A nurse is reinforcing teaching to a new mother regarding the purpose of administering vitamin K to her newborn following delivery. The nurse explains that the purpose of administering vitamin K is to prevent which of the following? A. Infection B. Potassium deficiency C. Bleeding D. Hyperbillirubinemia

C. Bleeding

A nurse is assisting with the admission of a client who is at 30 weeks of gestation and is in preterm labor. The provider prescribes betamethasone (Celestone) stat. When the client asks the nurse about the purpose of the medication, the nurse should reply that it will help A. Stop preterm labor contractions B. Halt cervical dilation C. Boost fetal lung maturity D. Increase the fetal heart rate

C. Boost fetal lung maturity

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings? A. Fetal heart rate irregularities B. Whitish vaginal discharge C. Excessive uterine enlargement D. Rapidly dropping human chronic gonadotropin levels

C. Excessive uterine enlargement

A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce to the client to call her provider if she experiences which of the following? A. Decreased energy B. Urinary frequency C. Facial edema D. Mood swings

C. Facial edema

A pregnant client tells the nurse she has constipation. What is the appropriate nursing recommendation for the client? A. Regular use of laxative B. Maintenance of good posture C. Increased cellulose and fluid in the diet D. Regular use of glycerine suppositories

C. Increased cellulose and fluid in the diet

A nurse is caring for a client who is admitted in preterm labor at 32 weeks of gestation. Which of the following prescriptions should the nurse question? A. Folic acid B. Ritodrine C. Misoprostol D. Trebutaline Sulfate

C. Misoprostol This medication can cause abortion, premature labor, and birth defect.

A nurse is completing a newborn gestational age assessment. Which of these findings is recorded as part of this assessment? A. Acrocyanosis of hands and feet B. Anterior fontanel soft and level C. Plantar creases cover 2/3 of sole D. Vernix caseosa in inguinal creases

C. Plantar creases cover 2/3 of sole

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 is 38.9 degrees C (102 degrees F). 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 C. Prepare to suppress uterine activity D. Prepare the client for membrane rupture

C. Prepare to suppress uterine activity

The nurse is administering dinoprostone gel to a client being seen in the prenatal clinic. The client asks the nurse what the medication is for. Which of the following is an appropriate response for the nurse to make? A. Stimulate uterine contractions B. Cause the client to abort the pregnancy C. Promote softening of the cervix D. Relax uterine contractions

C. Promote softening of the cervix

A nurse is caring for a client who is postpartum and requires Rho immune globulin (RhoGAM). Before administering it, the nurse should verify that the A. client is Rh positive and the newborn is Rh positive B. client is Rh negative and the newborn is Rh negative C. client is Rh negative and the newborn is Rh postive D. client is Rh positive and the newborn is Rh negative

C. client is Rh negative and the newborn is Rh postive

A nurse is caring for a client who is receiving oxytocin IV following a normal vaginal delivery. To evaluate the effectiveness of this medication, the nurse needs to check the client's A. urinary output B. blood pressure C. fundal consistency D. pulse rate

C. fundal consistency

A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following is an appropriate response? A. "Yes, it will, but if you decrease your fluid intake, especially at bedtime, it won't be so bothersome." B. "No, in most cases it only lasts until about the 12th week, but it will continue if you have poor bladder tone." C. "There is no way to predict how long it will last for each individual client, so you'll just have to wait and see." D. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy."

D. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy."