ATI PROCTORED EXAM - MATERNAL NEWBORN
A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include?
Correct Answer: C. Stress incontinence
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? Show Explanation
correct Answer: C. Infection
A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? Show Explanation
correct Answer: C. Oxytocin
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? Show Explanation
correct Answer: Copper intrauterine device
A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching?
Correct Answer: C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery."
A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent neural tube defects?
Correct Answer: D. Begin taking a folic acid supplement Adequate amounts of folic acid are necessary for fetal neural tube development. All women of child-bearing age and intention should take a folic acid supplement of 0.4 mg.
A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? Show Explanation
Correct Answer: "I may notice increased cramping when I am feeding my baby."
A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? Show Explanation
Correct Answer: "I should press the button on the handheld marker when my baby moves."
A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching?
Correct Answer: "I will place my baby on his back when putting him to sleep."
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include?
Correct Answer: "Place fresh cabbage leaves on your breasts."
A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide?
Correct Answer: "You should slightly increase your exposure to sunlight."
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. The amount available is morphine oral solution 0.4 mg/mL. How many mL should the nurse administer? (Fill in the blank with the numeric value only, round the answer to the nearest hundredth, and use a leading zero if applicable. Do not use a trailing zero.) Show Explanation
Correct Answer: 0.25
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching?
Correct Answer: B. "Place ice packs on your breasts."
A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make?
Correct Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common."
A nurse is caring for a primigravid client who is at 8 weeks gestation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make? Show Explanation
Correct Answer: B. "These feelings are quite normal at the beginning of pregnancy."
A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? Show Explanation
Correct Answer: B. Administer the hepatitis B vaccine prior to discharge
A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform?
Correct Answer: B. Assess the newborn's blood glucose level
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?
Correct Answer: B. Assess the newborn's blood glucose level
A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include?
Correct Answer: B. Discard opened cans of formula after 48 hr refrigeration.
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider?
Correct Answer: B. Double vision
A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include?
Correct Answer: B. Hypoglycemia
A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take?
Correct Answer: B. Increase the rate of the primary IV infusion
A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? Show Explanation
Correct Answer: B. Increase the rate of the primary IV infusion
A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development?
Correct Answer: B. Position the naked newborn on the parent's bare chest
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make?
Correct Answer: B."You will receive a medication to relax your uterus prior to the procedure."
A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include?
Correct Answer: B.Sponge bathe the newborn every other day
A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include?
Correct Answer: C. "A Doppler device can detect your baby's heart rate at 12 weeks."
A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? Show Explanation
Correct Answer: C. "I should be careful to avoid becoming pregnant within the next month."
A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? Show Explanation
Correct Answer: C. "I will feel the effects of the nitrous oxide almost immediately."
A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? Show Explanation
Correct Answer: C. Administer immune globulin to the client to prevent fetal isoimmunization
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? Show Explanation
Correct Answer: C. Assist the client to the toilet
The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU?
Correct Answer: C. Autosomal recessive
A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? Show Explanation
Correct Answer: C. Give oxygen at 10 L/min via face mask
A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block?
Correct Answer: C. Hypotension
A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take?
Correct Answer: C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows
A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? Show Explanation
Correct Answer: C. October 27
A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor?
Correct Answer: C. Palpating the client's fundus
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer?
Correct Answer: C. Calcium gluconate
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn?
Correct Answer: C.9
A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate? Show Explanation
Correct Answer: Calcium gluconate
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside?
Correct Answer: Calcium gluconate
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make?
Correct Answer: D. "A progestin-only pill or injection is available for use while you are breastfeeding."
A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements?
Correct Answer: D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make?
Correct Answer: D. "This is a source of your fluid loss after delivery."
A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?
Correct Answer: D. "You should continue to take zidovudine throughout the pregnancy."
A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching?
Correct Answer: D. "You should eat dry foods that are high in carbohydrates when you wake up."
A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?
Correct Answer: D. Apply pressure to the client's sacral area during contractions
A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching?
Correct Answer: D. Blurred or double vision
A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first?
Correct Answer: D. Dry the newborn
A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?
Correct Answer: D. Fetal gastrointestinal anomaly
A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? Show Explanation
Correct Answer: D. Gonorrhea
A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take?
Correct Answer: D. Instruct the client to apply cold compresses
A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?
Correct Answer: D. Slow-paced breathing
A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority?
Correct Answer: D. The fetal heart rate is 90/min.
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?
Correct Answer: D. Urine output 20 mL/hr
A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? Show Explanation
Correct Answer: Daily weight
A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? Show Explanation
Correct Answer: Dark brown vaginal discharge
A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects?
Correct Answer: Fetal asphyxia
A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?
Correct Answer: Fetal gastrointestinal anomaly
A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? Show Explanation
Correct Answer: Frequent headaches
A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? Show Explanation
Correct Answer: Massage the fundus
A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? Show Explanation
Correct Answer: Maternal hypotension
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?
Correct Answer: Pelvic inflammatory disease (PID)
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? Show Explanation
Correct Answer: Provide a sitz bath with warm water for the client
A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?
Correct Answer: Renal agenesis
A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect?
Correct Answer: Urinary retention
A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make?
Correct Answer: D. "This type of monitoring will allow us to measure the intensity of your contractions."
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching?
Correct Answer: D. Encourage non-nutritive sucking for pain relief
A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.)
Correct Answers: A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?
D. Use a photometer to monitor the lamp's energy
A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include?
Correct Answer: B. "If the test is positive, that means your baby's heart rate is healthy."
A nurse is teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include?
Correct Answer: A. "Apply ice packs to your breasts."
A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include?
Correct Answer: A. "Crib slats should be less than 2.25 inches apart."
A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner?
Correct Answer: A. "Lightly stroke the upper thighs."
A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? Show Explanation
Correct Answer: A. "Losing 2.2 pounds each month would be acceptable."
A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester?
Correct Answer: A. Accepting the pregnancy
A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? Show Explanation
Correct Answer: A. Ask the client to drink a glass of orange juice
A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer?
Correct Answer: A. Betamethasone
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend?
Correct Answer: A. Copper intrauterine device .
A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect?
Correct Answer: A. Painless, bright red bleeding
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?
Correct Answer: A. Palpable fetal movement
A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?
Correct Answer: A. Place the unwrapped newborn on the mother's bare chest.
A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take?
Correct Answer: A. Promote active movement in and out of bed
A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? Show Explanation
Correct Answer: A. Turn the newborn every 2 hr
A nurse is caring for a client at 37 weeks gestation who is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? Show Explanation
Correct Answer: A. Use vibroacoustic stimulation on the client's abdomen for 3 sec
A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta?
Correct Answer: A. Uterine tone
A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? Show Explanation
Correct Answer: A. Uterine tone
A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect?
Correct Answer: Abundant lanugo
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take?
Correct Answer: Apply cold ice packs to the client's perineum
A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? Show Explanation
Correct Answer: Ask the client when she last voided
A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take?
Correct Answer: Assess the newborn for respiratory depression
A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make?
Correct Answer: B. "I'm here for you if you would like to talk."
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect?
Dark red vaginal bleeding