ATI OB Proctored test/Adaptive Quizzes
A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take? A. Repeat the measurement immediately using the opposite arm B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes C. Repeat the measurement after repositioning the client so that her feet are off the floor D. Repeat the measurement while ensuring the client's arm is dangling at her side
Correct Answer: B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes Rationale: A blood pressure of 142/90 mmHg is elevated. When an elevated reading is obtained, the nurse should allow the client to rest for 5 to 10 minutes before repeating the measurement. Incorrect Answers: A. Repeating the blood pressure immediately can cause a false reading and should be avoided. C. To obtain an accurate blood pressure reading, the nurse should instruct the client to have both feet. D. To obtain an accurate blood pressure reading, the nurse should have the client's arm supported on a table.
A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. "Clean the lesions twice a day with hydrogen peroxide." B. "Apply a hot compress to the affected areas." C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." D. "Expect to receive penicillin prior to delivery."
Correct Answer: C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." Rationale: Acyclovir is an antiviral medication that helps reduce the manifestations of a genital herpes simplex infection. However, topical acyclovir is a pregnancy risk category C medication, so the provider and the client should weigh the risks and benefits of this therapy. Incorrect Answers: A. The nurse should instruct the client to clean the lesions twice per day with a saline solution. B. The nurse should instruct the client to take a warm sitz bath with baking soda in the water. D. Herpes simplex is a virus; penicillin treats bacterial infections, not viral infections.
A nurse is assessing a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first? A. Administer analgesia B. Administer carboprost IM C. Assist the client to the toilet D. Obtain a blood specimen to test Hct and Hgb levels
Correct Answer: C. Assist the client to the toilet Rationale: Evidence-based practice indicates that the nurse should rst help the client empty her bladder. Displacement of the fundus to the left indicates that the cause of the excessive bleeding is uterine atony due to bladder distention, so this action is the nurse's priority. Incorrect Answers: A. The nurse should administer analgesia because pain can prevent the client from emptying her bladder; however, evidence-based practice indicates that another action is priority. B. The nurse should administer a prescribed prostaglandin preparation to help control the bleeding; however, evidence-based practice indicates that another action is the priority. D. The nurse should obtain a blood specimen for Hct and Hgb to monitor the systemic effect of the client's blood loss and the effectiveness of treatment; however, evidence-based practice indicates that another action is the priority.
A nurse is caring for a client in the latent phase of labor who is receiving oxytocin via continuous IV infusion. The client is having contractions every 2 min that last 100 to 110 sec, and the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take? A. Decrease the infusion rate of the maintenance IV uid B. Administer oxygen via nonrebreather mask C. Decrease the dose of oxytocin by half D. Administer terbutaline 0.25 mg subcutaneously
Correct Answer: C. Decrease the dose of oxytocin by half Rationale: The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole. Incorrect Answers: A. The nurse should not decrease the rate of the maintenance IV uid because this will not alleviate the uterine tachysystole. B. The nurse should not administer oxygen to the client because this is an unnecessary intervention that will not address uterine tachysystole. The nurse should administer oxygen if the FHR is nonreassuring. D. The nurse should not administer terbutaline 0.25 mg subcutaneously to the client because this is an unnecessary intervention that will not address uterine tachysystole. The nurse should administer terbutaline if the FHR is nonreassuring
A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. Altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia
Correct Answer: C. Intracranial hemorrhage Rationale: Vitamin K, which is necessary for blood clotting, is produced by the action of bacteria in the gastrointestinal system. A newborn's gastrointestinal system is sterile and therefore deficient in vitamin K at birth. It needs to be supplemented to protect the newborn from bleeding until the gastrointestinal system is colonized with flora. Incorrect Answers: A. Vitamin K is necessary for blood clotting but does not affect amylase, an enzyme needed for digestion of carbohydrates that is not fully present in infant saliva until 3 months of age. B. Hyperbilirubinemia is caused by waste products from the breakdown of fetal red blood cells. Vitamin K does not have a role in this process. D. Insulin production occurs in the pancreas, and glycogen is produced in the liver. Vitamin K does not affect blood glucose.
A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? A. "My ankles are swollen at the end of the day." B. "I can feel the baby kicking my ribs, and it is very uncomfortable." C. "I'm growing more and more worried every day." D. "My heart feels like it is racing.
Correct Answer: D. "My heart feels like it's racing" Rationale: The nurse should apply the urgent versus non urgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. The nurse should assess the client's heart rate. The primary action of terbutaline involves bronchodilation and relaxation of smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Incorrect Answers: A. A client who is pregnant will normally have swollen ankles by the end of the day. During pregnancy, body uids and blood content increases, and some of this uid can shift to extracellular spaces. The nurse should assess the client's swelling. However, another nding is the nurse's priority. B. Fetal activity is an assessment of fetal wellbeing. Although fetal activity can be uncomfortable for the mother, another nding is the nurse's priority. C. Clients in preterm labor are often worried. The nurse should explore this comment by the client, but another nding is the priority.
A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor. B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery. C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum. D. The fundus is not palpable abdominally at 2 weeks
Correct Answer: D. The fundus is not palpable abdominally at 2 weeks postpartum Rationale: Involution is the return of the uterus to its normal pre pregnancy state, which occurs after the delivery of the placenta. By the end of the third stage of labor, the fundus is 2 cm below the umbilicus. Within 12 hours after delivery, the fundus rises 1 cm above the umbilicus. The fundus descends 1 to 2 cm (0.39 to 0.79 in) every 24 hours. The fundus is not palpable after the sixth postpartum day. Incorrect Answers: A. The fundus is approximately 2 cm (0.79 in) below the level of the umbilicus at the end of the third stage of labor. B. C. Within 12 hours after delivery, the fundus rises 1 cm (0.39 in) above the umbilicus. The fundus descends 1 to 2 cm (0.39 to 0.79 in) every 24 hours.
A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care? A. Apply lotion to the skin during phototherapy B. Supplement feedings with oral glucose water C. Cover the nares with an opaque mask D. Turn and reposition the newborn every 2 hours during phototherapy
Correct Answer: D. Turn and reposition the newborn every 2 hours during phototherapy Rationale: The nurse should turn and reposition the newborn at least every 2 to 3 hours to allow maximum exposure of skin surfaces to the phototherapy light. Incorrect Answers: A. Nurses should not apply any cream or lotion to the newborn's skin. Creams and lotions can absorb heat and cause burns while the newborn is undergoing phototherapy. B. It is important to hydrate the newborn during phototherapy with breast milk or formula. Glucose water and plain water do not promote the excretion of bilirubin in the stools, which facilitates the resolution of jaundice. C. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. Covering the nares is unnecessary and might interfere with respiration.
A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of information should the nurse provide for the client regarding the recommended weight gain during pregnancy? A. "You should plan to gain no more than 20 pounds during your pregnancy." B. "You should plan to gain between 25 and 35 pounds during your pregnancy." C. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." D. "Since you have higher energy needs than an average sized pregnant client, you should plan to gain 45 to 50
Correct answer: "You should plan to gain no more than 20 pounds during your pregnancy" Rationale: Woman who have a BMI above 30 should limit their weight gain to 11 to 20 pounds during pregnancy. Excessive weight gain can increase the risk of complications during and after the pregnancy. Incorrect Answers: B. This is the recommended weight gain for a pregnant client who has a BMI of 18.5 to 25. C. Pregnancy is not an appropriate time for the client to be dieting. Clients who are overweight or obese should be counseled to gain enough weight to compensate for the fetus, placenta, and amniotic uid, which amounts to 11 to 20 pounds. D. Women with a BMI above 30 should limit their weight gain to 11 to 20 pounds during pregnancy.
A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."
Correct answer: A. "I will apply petroleum jelly to my baby's penis for the first few days. Rationale: The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces. Incorrect Answers: B. Towelettes might contain alcohol, which would irritate the skin at the circumcision site. C. The client should not attempt to remove any yellow exudate or crusting, as they are part of the healing process. Disrupting these findings can cause pain and bleeding. D. Wrapping the penis could interfere with blood circulation to the healing circumcision site. Additionally, dry gauze could adhere to the incision and cause pain and bleeding when it is removed
A nurse is caring for a client who asks,"How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are rst felt in the pelvic area and then in the lower back and abdomen
Correct answer: A. "True contractions will begin irregularly and then become regular in timing." Rationale: False contractions begin and remain irregular, but true contractions will begin irregularly and become regular and predictable. Incorrect Answers: B. False contractions will usually go away if the client ambulates or goes to sleep, whereas true contractions will continue regardless of the client's activity level. C. False contractions do not increase in duration frequency, or intensity no matter how close the client is to her due date. If the frequency and duration are increasing, the contractions are considered true contractions. D. False contractions are felt in the client's abdomen and remain in the abdominal and groin area, whereas true contractions begin in the lower back and spread around to the abdomen
A nurse is assisting with fetal heart monitoring during labor for a client who is at 40 weeks of gestation. The nurse should identify that which of the following findings on the fetal monitoring tracing requires intervention? A. A fetal heart rate of 180/min for 15 minutes B. A deceleration that returns to baseline at the end of the contraction C. An acceleration of 20/min for 18 seconds during a contraction
Correct answer: A. A fetal heart rate of 180/min for 15 minutes Rationale: A heart rate of more than 160/min for 10 minutes or longer is considered fetal tachycardia, which can indicate fetal hypoxemia; therefore, this finding requires intervention by the nurse. Incorrect Answers: B. Early decelerations (when the fetal heart rate decreases but returns to baseline at the end of a uterine contraction) are harmless and do not require intervention. C. Accelerations in the fetal heart rate of at least 15/min for 15 seconds or more with a return to baseline less than 2 minutes later are an indication of fetal wellbeing and do not require intervention. D. Occasional variable decelerations are harmless and do not require intervention. However, persistent variable decelerations require intervention.
A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia laboratory studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add a calcium supplement to her diet
Correct answer: B. Advise the client to lie on her side Rationale: Dizziness after a pregnant client lies at on her back is a sign of supine hypotension, which is caused by compression of the vena cava from the weight of the pregnant uterus. Pregnant women should be advised to avoid lying in a supine position. Incorrect Answers: A. Dizziness on arising from a supine position is not a symptom of preeclampsia. Symptoms of preeclampsia include headaches, visual disturbances, swelling, and epigastric pain. C. Dizziness is not a sign that the fetus is in jeopardy. Changes in the amount or patterns of fetal movement could be an indication of fetal hypoxia or intrauterine fetal death. D. Dizziness is not a sign of calcium deficiency. Calcium supplementation may be indicated for a client who reports leg cramps.
A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease
Correct answer: B. Assess the newborn's glucose levels. Rationale: Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed. Incorrect Answers: A. The nurse should administer the HBV vaccine prior to discharge. There is no indication to administer the vaccine within 1 hour after birth. C. The nurse should not bathe the newborn until the newborn's temperature has stabilized in the extra-uterine environment. Ideally, the nurse should place the infant in skin-to-skin contact with the mother for at least the first 1 to 2 hours after birth. Alternately, the nurse can place the newborn under a radiant heat source and assess the newborn's temperature every hour until it is stabilized. D. The nurse should use a pulse oximeter to screen for congenital heart disease 24 to 48 hours after birth. If the nurse performs the screening prior to 12 hours after birth, acrocyanosis might alter the results.
A nurse is teaching a client who is at 10 weeks gestation about self-care management for common discomforts during pregnancy. Which of the following instructions should the nurse include? A. Douche every other day to minimize leukorrhea B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the third trimester D. Decrease uid intake to reduce urinary frequency
Correct answer: B. Consume frequent snacks to decrease episodes of nausea. Rationale: An empty or overloaded stomach can increase feelings of nausea. Incorrect Answers: A. Douching disrupts normal vaginal ora and can lead to vaginal infections. Leukorrhea is normal and has a protective function during pregnancy. C. Pregnant clients should maintain good dental hygiene and see a dentist as needed throughout pregnancy. Dental procedures, including x rays and the use of local anesthetics are considered safe during pregnancy. D. Pregnant woman should consume at least 2L of water each day to help prevent constipation caused by slowed gastrointestinal motility and iron supplements.
A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include? A. "The fibroid will shrink during the pregnancy." B. "The fibroid can increase the risk of postpartum hemorrhage." C. "You will receive an injection of medroxyprogesterone acetate to shrink the fibroid." D. "You will have to undergo a cesarean birth because of the fibroid."
Correct answer: B. The fibroid can increase the risk of postpartum hemorrhage. Rationale: Uterine fibroids can increase the risk of postpartum hemorrhage due to the increased blood supply to the uterus, which supports the fibroid. Incorrect Answers: A. Uterine fibroid tumors are more likely to grow during pregnancy in response to the increase in circulating estrogen. C. The client will undergo serial ultrasound examinations during pregnancy to monitor the broid. The provider will not surgically remove the fibroid during pregnancy due to the risk of fetal injury or death and maternal hemorrhage. D. The size and location of the broid will determine the safest method for delivery. If the client has a small broid that is not near the cervical os, she can have a vaginal delivery.
A nurse is teaching a client about breast feeding. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."
Correct answer: C. "I may notice increased cramping when I am feeding my baby." Rationale: The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction. Incorrect Answers: A. A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well established (in approximately 3 or 4 weeks). D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.
A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen
Correct answer: C. Continue routine monitoring. Rationale: The nurse should continue routine monitoring because the newborn's assessment findings indicate adaptation to extrauterine life. Incorrect Answers: A. The nurse should expect short periods of apnea for a 12-hour old newborn and should not perform chest percussion. B. The nurse should place the newborn in a side-lying position or supine to promote sleep and decrease the risk of respiratory distress. D. Manifestations of abnormal breathing patterns that can indicate a need for supplemental oxygen include tachypnea, nasal retractions, stridor, and gasping
A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? A. Place the client in an extreme Trendelenburg position B. Increase the IV uid infusion rate C. Manually apply upward pressure intravaginally on the presenting part D. Administer 8 to 10 L/min of oxygen via a nonrebreather face mask
Correct answer: C. Manually apply upward pressure intravaginally on the presenting part. Rationale: The greatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression. Therefore, the rst action the nurse should take is to insert a gloved hand into the vagina and apply upward pressure to the presenting part to move it away from the cord. Incorrect Answers: A. The nurse should place the client in an extreme Trendelenburg position, a knee chest position, or a modified Sims' position to use gravity to keep the pressure of the presenting part off the cord; however, another action is the priority. B. The nurse should increase the client's IV infusion rate to promote hydration; however, another action is the priority. D. The nurse should administer oxygen to help prevent fetal hypoxia; however, another action is the priority
A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? A. Monitor the client's intake and output B. Initiate a high-ber diet for the client C. Monitor the client's weight weekly D. Initiate bedrest with the head of the bed elevated
Correct answer: C. Monitor the client's weight weekly. Rationale: The nurse should weigh the client daily to monitor for uid overload. Incorrect Answers: A. The nurse should monitor the client's intake and output because blood ow to and from the heart increases for at least the rst 24 hours after delivery. This physiological change places a client who has cardiac disease at high risk of cardiac decompensation and uid overload. B. A client who has cardiac disease should follow a high- ber diet to prevent straining with bowel movements because the pushing effort (Valsalva maneuver) can result in cardiac stress. D. The nurse should initiate bedrest with the head of the bed elevated to promote rest and decrease the client's oxygen consumption.
A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriages? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen
Correct answer: C. Progesterone Rationale: Progesterone maintains the endometrium and has a relaxant effect on the uterus so the fetus is not expelled. Incorrect Answers: A. Oxytocin stimulates uterine contractions and is responsible for the excretion of milk during lactation. B. Prolactin prepares the breasts to synthesize and secrete milk. D. Estrogen stimulates uterine contractility and growth of the uterus and breast glandular tissue. Estrogen levels rise near the end of pregnancy to prepare for the onset of labor
A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately? A. Vaginal leukorrhea B. Shortness of breath C. Swelling of the face and fingers D. Lower back pain
Correct answer: C. Swelling of the face and finger Rationale: Swelling of the face, ngers, or area over the sacrum is an indication of hypertensive disorders such as eclampsia. The nurse should ensure these educational sessions include instructing clients about reporting such indications to their provider immediately Incorrect Answers: A. Leukorrhea is a white or grayish vaginal discharge that is an expected finding during pregnancy. There is no need to report this finding B. Shortness of breath is a common nding during the third trimester of pregnancy due to the enlarging uterus pushing the diaphragm upward. There is no need to report this finding unless the client has significant difficulty breathing. D. Lower back pain is a common nding during the second and third trimesters of pregnancy due to the change in the client's center of gravity from the enlarging uterus
A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill
Correct answer: C. Weak and irregular pulse Rationale: A weak, irregular, and rapid pulse can indicate postpartum hemorrhagic shock due to decreased oxygenation and perfusion to the heart. The client will need uid replacement and medical attention. Incorrect Answers: A. Decreased urinary output is a manifestation of hemorrhagic shock due to decreased renal perfusion. B. Rapid and shallow respirations are a sign of hemorrhagic shock due to the lungs lacking adequate oxygenation and perfusion. D. Cool and clammy skin is an indication of hemorrhagic shock due to poor circulation.
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine
Correct answer: D. Methylergonovine Rationale: Methylergonovine is an ergot alkaloid, which promotes uterine contractions. Incorrect Answers: A. The nurse should administer terbutaline, a smooth muscle relaxant, to a client who is experiencing preterm labor. B. The nurse should administer nifedipine, a smooth muscle relaxant, to a client who is experiencing preterm labor. C. The nurse should administer magnesium sulfate to a client who has preeclampsia to lower blood pressure and minimize the risk of seizures.
A nurse is assessing a client who is receiving morphine via a patient controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? A. Respiratory rate 14/min B. Temperature 37.8°C (100°F) C. Dizziness upon rising D. Urine output 20 mL/hr
Correct answer: D. Urine output 20 mL/hr Rationale: Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 mL/hr. The nurse should report this finding to the provider. Incorrect Answers: A. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within the expected reference range. B. This temperature is within the expected reference range. C. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should instruct the client to sit on the side of the bed before getting up, assist the client with ambulation, and implement general safety measures. However, it is not necessary to report this finding to the provider.
