ATI Practice B

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. drink solution 1 hour prior and fasting is not required

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. maintain fasting glucose between 60 and 99 avoid exercise during hyperglycemia

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." An adverse effect of terbutaline is hypokalemia, hyperglycemia, and hypotension. Administered subq every 4 hours for no longer than 24 hours.

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

"I will need this medication if I have an amniocentesis." Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?

"You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. check bathwater with elbow not hand

A nurse is evaluating the client following surgery. Which of the following findings indicate that the client is experiencing a potential complication of surgery that requires immediate follow-up?

95 temp, 94% O2, 90/60 BP, moist and cool skin (hypothermia), +1 pedal pulses (decreases circulation and perfusion)

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Active The nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds. early phase is characterized by 0 to 5 cm dilation and contractions every 2 to 30 minutes, each lasting 30 to 44 seconds

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

The priority intervention the nurse should perform is assess DTRs followed by assess for visual disturbances

Assess the client's deep tendon reflexes (DTRs) is correct. The priority intervention for the nurse is to assess the client's DTRs to check the reflex irritability. According to evidence-based practice, increased DTR reflex irritability places the client at a greater risk for seizure activity. Assess the client for visual disturbances is correct. According to evidence-based practice, the nurse's next priority intervention is to assess the client for visual changes, such as blurred vision and scotoma, which are caused by vasospasms and decreased amounts of blood flow to the retina. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until this time. The client is experiencing a headache, heartburn, and has elevated blood pressure, which can indicate preeclampsia.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.

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 tests should the nurse prepare the client?

Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

Blood glucose 30 mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider. normal HGB - 14 to 24 normal bilirubin - 2 to 6 normal WBC - 9000 to 30000

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

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. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

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?

Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

After reviewing the client's current assessment findings, the nurse should identify that the client is experiencing ectopic pregnancy as evidenced by RLQ tenderness

Ectopic pregnancy is correct. The client reports late menses, abdominal pain, and scant dark red vaginal spotting. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting on perineal pad, which are associated with ectopic pregnancy. The client also has a history of PID, which is a risk factor for ectopic pregnancy. Right lower quadrant abdominal tenderness is correct. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting, which are findings associated with ectopic pregnancy.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is performing an assessment on the client who delivered 48 hours ago. Which of the following findings should the nurse report to the provider?

Fundus 2 cm below the umbilicus is incorrect. The client's fundus is 2 cm below the umbilicus, which is within the expected reference range. The fundus descends at approximately 1 cm each day until it is no longer palpable; therefore, the nurse should not report this finding to the provider. Blood pressure 152/110 mm Hg is correct. The client's blood pressure is above the expected reference range. An elevated blood pressure can be an indication of anxiety or preeclampsia; therefore, the nurse should report this finding to the provider. +2 pitting edema is correct. The client has +2 pitting edema, which may not be indicative of any disorder but should be investigated, especially if it is occurring with other manifestations; therefore, the nurse should report this finding to the provider. Headache is correct. The client reports a headache that began 1 hr ago. A headache that coincides with an elevated blood pressure might be an indication of preeclampsia; therefore, the nurse should report this finding to the provider. Heartburn is correct. The client reports heartburn that began 1 hr ago. Although heartburn can occur after eating, the client is also experiencing other manifestations along with the heartburn; therefore, the nurse should report this finding to the provider. Light amount of lochia rubra is incorrect. The client has a light amount of lochia rubra, which is an expected finding for a client who is 24 hr postpartum; therefore, the nurse should not report this finding to the provider.

the nurse should first address the client's HR followed by clients vaginal spotting

Heart rate is correct. The nurse should first address the client's heart rate, which is above the expected reference range, to establish a baseline for continued monitoring. Vaginal spotting is correct. The nurse should next address the amount and characteristics of the client's vaginal spotting to establish a baseline for continued monitoring.

The nurse is preparing the client for surgery. Which of the following actions should the nurse take?

Inform the client to be NPO prior to surgery is correct. The nurse should inform the client to be NPO prior to surgery. This will prevent aspiration during surgery. Administer Rho D immune globulin prior to surgery is incorrect. The nurse should administer Rho D immune globulin after surgery. The client is Rh negative and could develop antibody formation if exposed to Rh positive blood. Prepare to administer AB positive blood products if needed is incorrect. The nurse should only administer O or B negative blood products if the client requires a blood transfusion. Any other blood types are incompatible and can cause a reaction. (client is B negative) Insert an 18-gauge peripheral IV prior to surgery is correct. The nurse should provide IV access prior to surgery by inserting a larger bore IV such as an 18- or 20-gauge. An IV is used to administer IV fluids or blood products during surgery. Explain the surgical procedure to the client is incorrect. The provider is responsible for explaining the procedure to the client. The nurse is responsible for ensuring that the client is fully informed about the surgery. Obtain a complete blood count is correct. The nurse should obtain a complete blood count to establish baseline data prior to surgery. Verify a consent form is signed by the client is correct. The nurse should verify that the client has signed a consent form for surgery. This is mandatory prior to any surgical procedure.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. client placed in semi-fowler's and messaging abdomen does not stimulate movement

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?

Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, hypotonia, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.

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 The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. LSA = LUQ RSA = RUQ ROA = RLQ

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

The nurse is reviewing the client's electronic medical record. Which of the following actions should the nurse take? Select the 5 actions that the nurse should perform.

Place on seizure precautions is correct. The nurse should place the client on seizure precautions because the client has preeclampsia and is receiving magnesium sulfate. Administer magnesium sulfate IV bolus as prescribed is correct. The nurse should administer magnesium sulfate IV bolus as prescribed because this medication helps to prevent the client from progressing to eclampsia. Monitor the client's blood pressure every hour is incorrect. The nurse should monitor the blood pressure of a client who is receiving magnesium sulfate every 15 to 30 min. Obtain the creatinine, platelet, BUN, and liver enzymes values as prescribed is correct. The nurse should obtain baseline laboratory values to monitor progression of the client's condition. Assess for worsening headache and epigastric pain hourly and PRN is correct. The nurse should assess for worsening headache and epigastric pain to determine if the client's condition is deteriorating. Monitor level of consciousness, DTRs, and visual disturbances hourly is correct. The nurse should monitor the client's level of consciousness, DTRs, and visual disturbances hourly and PRN to determine if the client's condition is deteriorating.

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?

Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider?

Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. breakthrough bleeding, vomiting, and breast tenderness are all common adverse effects of oral contraceptives

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?

Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. suction mouth before nares

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. An audible murmur heard at the left sternal border is an expected manifestation in newborns.

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 Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Transvaginal ultrasound is indicated. The nurse should anticipate a prescription for a transvaginal ultrasound. A transvaginal ultrasound is useful in determining the location of the ectopic pregnancy. Meperidine IM is contraindicated. Clients who receive methotrexate for an ectopic pregnancy should not take analgesics stronger than acetaminophen, because these medications can mask the manifestations of tubal rupture. Repeat quantitative β-hCG level is anticipated. The quantitative β-hCG level should be repeated within 48 hr to see if the level has changed from last recording. If increased levels are identified with no intrauterine pregnancy on ultrasound, this is indicative of ectopic pregnancy. Methotrexate IM is anticipated. The nurse should anticipate a prescription for methotrexate IM administration to prevent further embryonic cell reproduction. Blood typing is anticipated. The nurse should also anticipate potential surgical intervention for the client; therefore, blood typing is indicated.

The nurse is planning care for the postpartum client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Urinalysis is anticipated. The nurse should anticipate a prescription for a urinalysis. A urinalysis will reveal the presence of increased levels of protein in the urine, which might be indicative of preeclampsia. Monitor intake and output is anticipated. Magnesium sulfate is anticipated. The nurse should anticipate a prescription for magnesium sulfate. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. Clients who have headaches, visual disturbances, and increased DTR irritability should be administered magnesium sulfate to help prevent seizure activity in the postpartum period. Place the client on seizure precautions is anticipated. The nurse should anticipate a prescription for seizure precautions. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. The client is exhibiting manifestations of preeclampsia and could progress to eclampsia (seizures). Labetalol is contraindicated. The nurse should not anticipate a prescription for labetalol. This medication is contraindicated for clients who have asthma. This client's medical history includes asthma; therefore, the client should not be prescribed this medication. Draw creatinine and BUN is anticipated. The nurse should anticipate a prescription for creatinine and BUN labs to be drawn. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. Increased creatinine levels are used to determine if kidney function is impaired. BUN levels can indicate impaired kidney function as well.

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

Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. others include: tachypnea, low birth weight, and hypoglycemia

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

chin quivering, grimacing, furrowing of the brow, increased HR, dilated pupils, rapid and shallow respirations

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)

cholecystitis, HTN, and migraines

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

flaccid uterus and excess vaginal bleeding oxytocin will increase afterbirth cramping and will have no effect on maternal temperature