Maternal/Newborn ATI Practice Tests

A nurse is assessing the newborn of a client who took a SSRI during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? a. LGA b. hyperglycemia c. bradypnea d. vomiting

d. vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

A nurse is assessing a client who is at 38 weeks gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? a. blood pressure 136/88 b. reports of insomnia c. weight gain of 2.2 kg/4.8 lb d. report of Braxton Hicks contractions

c. weight gain of 2.2 kg/4.8 lb A weight gain of this much in a week is above the expected reference range and could indicate complications.

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? a. Hct 39% b. serum albumin 4.5 g/dl c. WBC 9000 d. platelets 50,000

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

Order of bathing a Newborn

1. wipe eyes from inner canthus outward 2. wash newborn's neck by lifting the chin 3. cleanse skin around newborn's umbilical cord stump 4. wash legs and feet 5. cleanse diaper area

Steps of Leopold Maneuver

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.

First step in Leopold Maneuver

The nurse palpates the client's abdomen to determine which fetal part is in the fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? a. a client who is at 11 weeks gestation and reports abdominal cramping b. a client who is at 15 weeks gestation and reports tingling/numbness in the right hand c. a client who is 20 weeks gestation and reports constipation the past 4 days d. a client who is at 8 weeks gestation and reports having three bloody noses in the past week

a. a client who is at 11 weeks gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine the priority finding is this. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should report that the provider see this client first.

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. abruptio placenta b. placenta previa c. preeclampsia d. maternal bradycardia

a. abruptio placenta Cocaine use increases vasoconstriction and possible risk of abruptio placenta

A nurse is caring for a client who is at 36 weeks gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? a. biophysical profile b. amniocentesis c. cordocentesis d. Kleihauer-Betke test

a. biophysical profile A + contraction stress test indicates that further evaluation is necessary. A biophysical profile will provide further evaluation with a real-time US

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? a. hemoglobin 10 g/dl b. WBC count 10,000 mm3 c. platelets 250,000 mm3 d. fasting blood glucose 90 mg/dl

a. hemoglobin 10 g/dl A hemoglobin of 10 is below the expected reference range of greater than 11 g/dl for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia

A nurse is caring for a prenatal client who has parvovirus (5th disease). Which of the following actions should the nurse take? a. administer antiviral medication b. schedule an ultrasound c. administer Haemophilus influenzae type b vaccine d. schedule and indirect Coomb's test

b. The nurse should schedule serial US exams to monitor the fetus during pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, IUGR, fetal anemia, or stillbirth

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? a. "I will not gain more than 15-20 lbs during my pregnancy" b. "I will likely need to use alternative positions for sexual intercourse" c. "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy" d. "I'm glad I have a light complexion and will not get any stretch marks"

b. "I will likely need to use alternative positions for sexual intercourse" The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? a. "You can resume sexual activity in 1 week" b. "You won't need to do Kegel exercises since you had a cesarean" c. "You can still become pregnant if you are breastfeeding" d. "You are safe to start adding sit-ups to your exercise routine in 2 weeks"

c. "You can still become pregnant when breastfeeding" The nurse should instruct the client that breastfeeding doesn't prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe while breastfeeding.

A nurse is caring for a client who is anemic at 32 weeks gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? a. decreased uterine contractions b. an increase in the client's hemoglobin levels c. a reduction of respiratory distress in the newborn d. increased production of antibodies in the newborn

c. a reduction in respiratory distress in the newborn Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress

A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? a. monitor FHR b. assess uterine activity c. administer oxygen via nonrebreather d. start a bolus of IV fluid

c. administer oxygen via nonrebreather When using the ABC approach to client care, the nurse should place the priority on administering oxygen to the client via nonrebreather at 10 L/min to ensure adequate oxygenation to the fetus

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? SATA cholecystitis, hypertension, HPV, migraine headaches, anxiety disorder

cholecystitis, hypertension, migraine headaches

A nurse is teaching a client who is at 10 weeks gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I should increase my protein intake to 60 grams a day" b. "I should drink 2 L of water a day" c. "I should increase my overall daily caloric intake by 300 calories" d. "I should take 600 micrograms of folic acid each day"

d. "I should take 600 micrograms of folic acid each day" A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.

A nurse is performing a routine assessment on a client who is at 18 weeks gestation. Which of the following findings should the nurse expect? a. deep tendon reflexes 4+ b. fundal height of 14 cm c. urine protein 2+ d. FHR 152/min

d. FHR 152/min

A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke." Which of the following interventions is the nurses priority? a. perform Nitrazine testing b. assess the fluid c. check cervical dilation d. begin FHR monitoring

d. begin FHR monitoring The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority aciton.

Should a breastfeeding mom on methadone D/C breastfeeding?

No. The nurse should encourage the mother to continue to breastfeed on demand. Breastfeeding will assist to decrease manifestations of NAS in the newborn.

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? a. Kleihauer-Betke test b. progesterone serum level c. lecithin/sphingomyelin ratio d. maternal alpha-fetoprotein

a. kleihauer-betke test The nurse should expect the provider to prescribe this test for a client who has suspected placental abruption to determine if the fetal blood is in maternal circulation. This test is useful to determine if Rho immune globulin therapy should be administered to a client who is rh-negative

A nurse is providing teaching to a client who is at 40 weeks gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? a. "I can administer oxytocin 4 hrs after the insertion of the medication" b. "you will need a full bladder prior to the insertion of the medication" c. "remain in a side-lying position for 15 mins after the medication is inserted" d. "an antacid will be given 20 mins prior to the insertion of the medication"

a. "I can administer oxytocin 4 hrs after the insertion of the medication" The nurse can administer oxytocin no sooner than 4 hrs after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and haven't begun labor.

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? a. apply sacral counterpressure b. perform transcutaneous electrical nerve stimulation c. initiate slow paced breathing d. assist with biofeedback

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

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? a. hypertension b. hypothermia c. constipation d. muscle weakness

a. hypertension The nurse should recognize carboprost is a vasoconstrictor that can cause hypertension

A nurse is performing a vaginal exam on a client who is in labor and observes the umbilical cord protruding out. After calling for assistance, which of the following actions should the nurse take? a. insert two gloved fingers into the vagina and apply upward pressure to the presenting part b. wrap the visible cord tightly with sterile, dry gauze c. apply oxygen at 2 L/min via NC d. place the client in the lithotomy and apply fundal pressure

a. insert two gloved fingers into the vagina and apply upward pressure to the presenting part The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve cord compression and increase oxygenation to the fetus

A nurse is caring for a client who is about to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin and should be reported to the provider? a. late decelerations b. moderate variability of FHR c. cessation of uterine dilation d. prolonged active phase of labor

a. late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported

A nurse is observing a new parent caring for their crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? a. lays the newborn across their lap and gently sways b. places the newborn in the crib in a prone position c. offers the newborn a pacifier dipped in formula d. prepares a bottle of formula mixed with rice cereal

a. lays the newborn across their lap and gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.

A nurse is assessing a newborn who was born at 26 weeks gestation using the New Ballard Score. Which of the following findings should the nurse expect? a. minimal arm recoil b. popliteal angle of 90 c. creases over the entire foot sole d. raised areolas with 3-4 mm buds

a. minimal arm recoil The nurse should expect a newborn who was born at 26 weeks to have decreased muscular tone

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? a. protect the client's head and feet from cold air b. bathe the client within 12 hrs following birth c. ambulate the client 24 hr following birth d. offer the client a glass of cold milk with her first meal

a. protect the client's head and feet from cold air Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period

A nurse is assessing a client who is 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? a. swelling of the face b. varicose veins within the calves c. nonpitting 1+ ankle edema d. hyperpigmentation of the cheeks

a. 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 transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? a. verify that the parent's identification band matches the newborn's identification band b. scan the newborn's identification band to verify their identity c. check the newborn's security tag number to ensure it matches the newborn's medical record d. match the newborn's date and time of birth to the information in the parent's medical record

a. verify that the parent's identification band matches the newborn's identification band The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's ID band to the information on the newborn's.

A nurse is performing a physical assessmen of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (SATA) yellow sclera, acrocyanosis, positive babinski, two umbilical arteries visible, posterior fontanel larger than anterior fontanel

acrocyanosis, positive babinski, 2 umbilical arteries visible

A nurse is caring for a client who is at 38 weeks gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. determine the progression of dilation & effacement b. perform Leopold maneuvers c. complete a sterile speculum exam d. prepare a nitrazine paper test

b. perform Leopold maneuvers The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer

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 priority? a. O2 saturation b. temperature c. blood pressure d. urinary output

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

A nurse is caring for a client who is at 36 weeks gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? a. to estimate the fetal weight b. to locate a pocket of fluid c. to determine multiparity d. to prescreen for fetal abnormalities

b. to locate a pocket of fluid An US is done to locate a pocket of amniotic fluid and the placenta prior to amniocentesis. This decreases the risk of injury to the fetus

A nurse is assessing a client who is 1 day PP and has a vaginal hematoma. Which of the following manifestations should the nurse expect? a. lochia serosa b. vaginal pressure c. intermittent vaginal pain d. yellow exudate vaginal drainage

b. vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to blood that leaked into the tissues

A nurse is teaching a newly licensed nurse about collecting specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? a. "Obtain an informed consent prior to obtaining the specimen" b. "Collect at least 1 mL of urine for the test: c. "Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen" d. "Premature newborns may have false negative tests due to immature development of liver enzymes"

c. "Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen" The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hrs prior to testing

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? a. "I will get injections of the medication once daily until my labor stops" b. "My blood sugar may be low while I'm on this medication" c. "I will have blood tests because my potassium might decrease" d. "My blood pressure may increase while I'm on this medication"

c. "I will have blood tests because my potassium might decrease" An adverse effect of terbutaline is hypokalemia

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to be right above the umbilicus. Which of the following actions should the nurse perform? a. reassess the client in 2 hrs b. administer simethicone c. assist the client to empty her bladder d. instruct the client to lie on her right side

c. assist the client to empty her bladder The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? Medical Record: BP 130/78, RR 20, HR 90, Hg 12, Hct 34%, 1-hr glucose tolerance test 120, fundal height 30 cm, FHR 110/min a. 1-hr glucose tolerance test b. hematocrit c. fundal height d. fetal heart rat

c. fundal height A fundal height measurement of 30 cm should be reported. Fundal height should be the same as the number of gestational weeks, plus or minus 2.

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? a. left upper quadrant b. right upper quadrant c. left lower quadrant d. right lower quadrant

c. left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the lower left quadrant

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? a. place the client in a supine position for 30 mins following the first dose of anesthetic solution b. administer 1000 mL of dextrose 5% in water prior to the first dose of anesthetic solution c. monitor the client's blood pressure every 5 mins following the first dose d. ensure the client has been NPO 4 hr prior

c. monitor the client's blood pressure every 5 mins The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5-10 minutes to assess for maternal hypotension caused by the anesthetic

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? a. allow the sibling to hold the newborn during a bath b. make sure the sibling kisses the newborn each night c. obtain a gift from the newborn to present to the sibling d. switch the sibling's room with the nursery

c. obtain a gift from the newborn to present to the sibling Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling doesn't feel left out and that they understand their role in the family.

A nurse is assessing a newborn who was delivered vaginally with a tight nuchal cord. Which of the following findings should the nurse expect? a. bruising over the buttocks b. hard nodules on the roof of the mouth c. petechiae over the head d. bilateral periauricular papillomas

c. petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck

A nurse is caring for a client who is at 30 weeks gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? a. client reports nausea b. urinary output of 40 ml/hr c. respiratory rate 10/min d. client reports feeling flushed

c. respiratory rate 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.

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 adjustmen? a. discuss contraceptive options with the client & her partner b. repeat info to ensure understanding c. listen to the client and her partner as they reflect upon the birthing experience d. demonstrate to the client how to perform a newborn bath

d. 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 is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? a. check client's temperature b. observe for uterine contractions c. administer Rho immune globulin d. monitor FHR

d. monitor FHR The greatest risk to the client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following amniocentesis.

A nurse is preparing to collect a blood specimen from a newborn via heel stick. Which of the following techniques should the nurse use to help minimize the pain of procedure for the newborn? a. apply a cool pack for 10 mins prior to heel puncture b. request a prescription for an IM analgesic c. use a manual lance blade to pierce the skin d. place the newborn skin-to-skin on the mother's chest

d. place the newborn skin-to-skin on the mother's chest Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? a. hypertonia b. increased feeding c. hyperthermia d. respiratory distress

d. respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations include abnormal cry, jitteriness, lethargy, poor feeding, apnea, seizures

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? a. insert the syringe tip before compressing the bulb b. suction each of the nares before suctioning the mouth c. insert the tip of the syringe into the center of the newborn's mouth d. stop suctioning when the newborn's cry sounds clear

d. 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.