ATI Maternal born final

A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

"I will warm the bottle of formula by placing it in a pan of hot water"

A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take?

Instruct the client about vena cava syndrome and measure to prevent it

a nurse is preparing a client who is pregnant for an ultrasound. which of the following information is the most important for the nurse to collect? a. the time of the client's las void b. Who will accompany the client to the ultrasound c. The date of the client's last menstrual period d. Whether or not the client wants to know the sex of the fetus.

a

A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Nagele's ruel, Which of the following is the client's expected date of birth (EDB)? a. April 1 b. April 15 c. October 15 d. October 1

b. April 15

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan?

"you and your partner need to take the medication and use a condom during intercourse until cultures are negative"

a nurse is caring for four newborns. which of the following newborns is at greatest risk for hypoglycemia? a. A newborn who is a large for gestational age b. A newborn who has an Rh incompatitbility c. A newborn who has pathologic jaundice d. A newborn who has fetal alcohol sysndrome.

A. a newborn who is large for gestational age (LGA) large for gestational age newborn are those whose weight is at or above 90%. One of the most common etiologies of LGA newborn is the diabetic mother. LGA newborn ,especially those born to mothers who have diabetes, ae at increased risk for hypoglycemia. Other newborns at risk for hypogycemia are small of gestational age (SGA) new born ( those below 10% ),premature newborn , and newborn who have perinatal hypoxia.

A nurse is collection data on a newborn who was born at 43 wks of gestation. Which of the following finding should the nurse expect? a. Absent vernix b. Abundant lanugo c. Increased subcutaneous fat d.Short, brittle nails

A. absent vernix Vernix is a white substance that covers the skin the newborn starting at 18 wks of gestation. Vernix keeps the skin soft and provides a protective barrier for the newborn. Postterm newborn will not have vernix.

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. What action should the nurse include in the plan of care. a. maintain NPO status until the newborns bilirubin is within expected reference range b. swaddle the newborn in a receiving blanket during the treatment c. ensure the newborns eyes are closed before applying the eye shield d. apply lotion to the newborns skin twice per day

C. Ensure the newborn's eyes are closed before apply the eye shield. overexplosure to the light during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eye prior to applying the eyeshield.

A nurse is reinforcing teaching about oxytocin with a client who is in the 3rd trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for use of this medication? a. prolong rupture of membranes at 38 wks of gestation b. Intrauterine growth restriction c. Active genital herpes d. Posterm pregnancy.

C. active genital herpes. The use of oxytocin is contraindicated for clients who have active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

a nurse is discussing diaphragm use with a client. which of the following statements by the client indicates an understanding of the teaching?

I should replace my diaphragm every 2 years. Diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should replaced every 2 years.

A nurse is teaching a client about a nonstress test. What statment by the client indicates an understanding of the teaching? a. I should press the button on the handheld marker when my baby moves b. I know not to eat anything after midnight c. I will have to stimulate my breast to cause contractions d. I will have meds given to me to cause contractions

a. I should press the button on the handheld marker when my baby moves the purpose of a nonstress test is to assess fetal well-being. The client should press the button on the hand held marker when she feels fetal movement.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. What finding is a risk factor for an ectopic pregnancy? a. PID b. frequent UTIs c. anemia d. previous c-section

a. PID

A nurse is preparing to elicit the fencing reflex from a newborn. Which of the following actions should the nurse take? a. Turn the newborn's head quickly to one side. b. Clap loundly directly above the newborn c. Tap the bridge of the newborn's nose when his eyes are open d.Extend one of the newborn's legs and press down on the extended leg's knee.

a. Turn the newborn's head quickly to one side.

A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. What nursing actions should the nurse identify as a contraindication for the care of the newborn? a. frequent stimulation b. promoting maternal-newborn bonding c. tight swaddling of the newborn d. small frequent feedings

a. frequent stimulation

A nurse is caring for a client who is at 16 wks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. What methods should the nurse use to administer the med? a. use a 20 gauge needle, administer the med using the z-track method b. use an 18 gauge needle, administer the med into the rectus femoris muscle c. use a 25 gauge needle, and administer the med into the deltoid muscle d. use a 22 gauge needle, administer the med deep into the thigh

a. use a 20 gauge needle, administer the med using the z-track method The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20 gauge needle is the correct size.

a nurse is reinforcing teaching with a client who is postpartum and breastfeeding. which of the following nutrients should the nurse include in the teaching as a nutrient for the client to increase the intake of while breastfeeding? a. Vitamin C b. Iron c. Folate d. Calcium

a. vitamin C

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus type 2. which of the following statements by the nurse should be included in the teaching? a. "you will have a cesarean birth prior to the onset of labor" b. "you baby will receive erythromycin eye ointment after birth to treat the infection." c. "you should take oral metronidazole for 7days prior to 37wks of gestation. d. "you should schedule a cesarean birth after your water break"

a. you will have a cesarean birth prior to onset of labor

a nurse is assisting with the care of a newborn who has myelomeningocele. which of the following actions should the nurse take? a. Place the newborn in an infant carrier. b. Initiate a latex free environment c. cover the sac with a large dry gauze. d. Obtain a rectal temperature every 4 hrs.

b. Initiate a latex free environment

a nurse is caring for a client who is 2 hr postpartum. the nurse notes that the clients perineal pad has a large amount of loch ruby with several clots. which of the following actions should the nurse take first. a. Check for a full bladder. b. Massage the fundus c. Measure a vital sign. d. Administer carboprost IM

b. Massage the fundus The primary cause of early postpartum bleeding is uterine atony manifested by a relax , boggy uterus. So, the greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first.

A nurse is caring for a client who has a script for naloxone. What is the intended action of the med in relation to the CNS? a. depress activity of the CNS b. block effects of narcotics on the CNS c. accentuate effects of narcotic on the CNS d. stimulate activity of the CNS

b. block effects of narcotics on the CNS

A nurse is caring for a newborn who has irregular respirations of 52 with several periods of apnea lasting approx. 5 seconds. The newborn is pink with acrocyanosis. What action should the nurse take? a. assess the newborn's blood glucose b. continue to routinely monitor the newborn c. place the newborn in an isolette d. administer oxygen

b. continue to routinely monitor the newborn. This newborn is exhibiting a normal respiratory rate and rhythm. No addtional measure are need this time.

A nurse is planning care for a client who is at 35 wks gestation. What lab test should the nurse obtain? a. rubella titer b. group B strep beta hemolytic c. 1hr glucose tolerance test d. blood type

b. group B strep beta hemolytic

A nurse is contributing to the plan of care for a client who plans to formula feed her newborn. Which of the following actions should the nurse include in the plan? a. suggest that the client stand under a hot shower with her breasts exposed 2x/day b. have the client place ice packs on her breasts 4x/day c. have the client avoid wearing a bra for 14 days d. encourage the client to stimulate her nipples daily

b. have the client place ice packs on her breasts 4x/day Engorgement can occur in the non-breastfeeding client. For some clients, it is uncomfortable, and occasionally painful. Ice application to the breasts for 15 - 20 min, four times per day for 5 day. avoiding breast stimulation keeping warm water off of the breasts during showering are effective method to reduce milk production and suppress lactation.

A nurse is caring for a client who is at 34 wks gestation and has a script for terbutaline for preterm labor. What statement by the client is the priority? a. my ankles are swollen at the end of the day b. my heart feels as if it is racing c. I'm growing more and more worried every day d. I can feel the baby kicking my ribs, and it is very uncomfortable

b. my heart feels as if it is racing

A nurse is caring for a client who is at 36 wks gestation and has pre-eclampsia. What finding should the nurse identify as the priority? a. bp 140/98 b. nonreactive nonstress test c. 1+ proteinuria d. fundal ht 33 cm

b. nonreactive nonstress test

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for wt. The client asks the nurse how much weight is safe for her to gain during pregnancy. What response should the nurse make? a. wt gain of about 14 lbs each trimester is suggested b. wt gain of 25-35 lbs is good c. your provider can discuss an appropriate amount of wt gain with you d. if you eat nutritious foods when you feel hungry, the amount of wt gain is insignificant

b. wt gain of 25-35 lbs is good A weight gain of 25-30 lbs is associated with good fetal outcome. A gain of 4lbs in the first trimester and 12 lb each for the second and third trimester is recommended.

A nurse is caring for a client who is pregnant and reports nausea and vomiting. What instructions should the nurse provide the client? a. you should sip whole milk with breakfast b. you should eat some crackers before rising from bed in the morning c. you should brush your teeth immediately after meals d. you should eat foods served at warm temps

b. you should eat some crackers before rising from bed in the morning

a nurse is reinforcing teaching with a client who is breastfeeding. which of the following information should the nurse include? a. " You should allow your baby to nurse for a total of 20 mins per feeding" b. " Your baby should have five wet diapers per day" c. " Your baby should have bursts of 15 sucks or swallow at a time." d. " Your can expect your baby to have dark black stools for the first weeks of life.

c. " Your baby should have bursts of 15 sucks or swallow at a time."

a nurse administers betamethasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When assisting with the plan of care for the newborn, which of the following conditions should the nurse identify as an adverse effect of the medication? a. Hyperthermia b. Irritability c. Decrease blood glucose d. Rapid pulse rate.

c. Decrease blood glucose. Betamethasone causes hyperglycemia in the client, which predispose the newborn to hypoglycemia in the first hours after delivery. It is important to check the newborn's blood glucose level within the first hour following birth and frequently therafter until blood glucose level are stable.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. What finding should the nurse identify as a potential complication from the oxygen therapy? a. necrotizing enterocolitis b. interstitial emphysema c. retinopathy d. atelectases

c. Ratinopaty. O2 therapy can cause retinopathy of prematurity, especially preterm newborn. Retinopathy is a disorder of retinal blood vessel development in the premature newborn. In newborn who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fill back of the eye. It can reduce vision or result in complete blindness.

A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temp 37.3C (99.2F), and pulse 52. What action should the nurse take? a. report the vitals to the provider b. administer oxytocin agent c. ask the client when she last voided d. massage the fundus

c. ask the client when she last voided

A nurse is planning care for a client who is pregnant and is Rh-negative. In what situation should the nurse administer Rh(D) immune globulin a. following an episode of influenza during pregnancy b. prior to a blood transfusion c. at 28 wks gestation d. while the client is in labor

c. at 28 wks gestation

A nurse is caring for a newborn who has neonatal abstinence syndrome. What clinical findings should the nurse expect? a. poor muscle tone b. respiratory rate 50/ min c. exaggerated reflexes d. extended periods of sleep

c. exaggerated reflexes A newborn who has neonatal abstinence sysdrome usually exhibits clinical finding of hyperactivity within the cns system. Exaggerated reflexed are indicative of CNS irritability.

A nurse is caring for a client who desires an intrauterine device for contraception. What finding is a contradiction for the use of this device? a. hx of multiple gestations b. hx of thromboembolic disease c. menorrhagia d. HTN

c. menorrhagia

A nurse is assessing a newborn who is 12 hr old and notes mild jaundice of the face and trunk. What actions should the nurse take? a. administer phytonadione IM b. perform gestational age assessment c. obtain a stat script for a bilirubin level d. obtain a bagged urine specimen

c. obtain a stat script for a bilirubin level

A nurse is caring for a client who is at 8 wks gestation with twins and primigravida. The client states that even though she and her husband planned the pregnancy, she is experiencing ambivalent feelings about it. What responses should the nurse make? a. perhaps you should see a counselor to discuss these feelings b. I am quite concerned about these feelings. Could you explain more? c. these feelings are quite normal at the beginning of the pregnancy d. have you told your husband about these feelings?

c. these feelings are quite normal at the beginning of the pregnancy

A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include.? a. " take 600 milligram of ibuprofen as needed for discomfort" b. " you should eat soft cheeses to increase your calcium intake" c. " you should roll your nipples daily to ensure they are everted" d. " you should use fluoride-based toothpaste to prevent dental care"

d. " you should use fluoride-based toothpaste to prevent dental care" Nausea during pregnancy can lead to poor oral hygiene and inflammation of the gingival tissue, which can lead to dental caries. the nurse should instruct the client to use a fluoride-based toothpaste during pregnancy.

a nurse is collecting data on a client who is at 8 weeks of gestation. which of the following findings should the nurse report to the provider? a. WBC 14,000/ mm3 b. Hgb 11.5 g/dl c. A blood pressure variation of 10 mm Hg between arms. d. Small amount of brown vaginal discharge

d. Small amount of brown vaginal discharge. a small of brown vaginal discharge can be warn sign of an ectopic pregnancy is where the fertilized ovum is implanted outside of the uterus. The nurse should report this finding to the provider.

A nurse is caring for four newborns. which of the following findings should the nurse report to the provider? a 1 hr old newborn who has a blood glucose of 55 mg/dL b. an 8 hr old newborn who has a respiratory rate of 50/min c. a 24 hr old newborn whose chest circumference is 32 cm d. a 12 hr old newborn who has a heart rate of 70/min while sleeping

d. a 12 hr old newborn who has a heart rate of 70/min while sleeping Note: Average HR for newborn 80 -100 min while sleeping The average chest circumstance of a new born is 30-33 cm. Average respiratory rate for newborn 30-60 /min A blood glucose range of 55 mg/dl is within the expected reference range.

A nurse is providing d/c teaching to a client following the removal of hydatidiform mole. What statement should the nurse include? a. seek genetic counseling for yourself and your partner prior to getting pregnant again b. you should have and hCG level drawn in 6 wks c. have your bp checked wkly for the next month d. do not become pregnant for at least 1 yr

d. do not become pregnant for at least 1 yr Hydatidiform moles are uncontrolled growths in the uterus arising form placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies'. Pregnancy must be avoided for 1 years so the client can be closely monitored for manifestation of this conditon

a nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving his wife since the pregnancy was announced several weeks ago. which of the following responses should the nurse make? a. I'm sure that it is really hard to accept this when it is your baby too b. it would be wise for you to speak to a therapist about these feelings c. has your wife sensed your anger toward her and the baby? d. these feelings are common to expectant fathers in early pregnancy

d. these feelings are common for expectant fathers in early pregnancy