ATI- Maternity Practice Test A
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a c-section. The nurse notes RR of 8 breaths/min. Which of the following meds should the nurse adminster? A) Fentanyl B) Butorphanol C) Naloxone D) Meperidine
C) Naloxone Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client.
A nurse is performing a vaginal assessment on a client who is in labor and observes the umbilical cord protruding from the vagina . 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 to the client at 2 L/min via nasal cannula. D) Place the client in the lithotomy position 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 umbilical cord compression and increase oxygenation to the fetus.
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? A) Reports increased urinary output B) Diaphoresis C) Reports blurred vision D) Shallow respirations
A) Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure on the newborn? A) Apply a cool pack for 10 min to the heel prior to the puncture. B) Request a prescription for 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. The nurse should implement this technique before, during, and after the procedure.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? BP 130/78 mm Hg, RR 20/min HR 90/min Hgb 12 g/dL Hct 34%1-hr glucose tolerance test 120 mg/dL Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding FHR 110/min 1-hr glucose tolerance test Hematocrit Fundal height measurement Fetal heart rate (FHR)
Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.
A nurse is assessing a newborn wh is 16 hr old. Which of the following findings should the nurse report to the provider? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in)
Substernal retractions The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention.
A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." "I will likely need to use alternative positions for sexual intercourse." "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." "I'm glad I have a light complexion and will not get any stretch marks."
"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 teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? "The test should take 10 to 15 minutes to complete." "You will lay in a supine position throughout the test." "You should not eat or drink for 2 hours before the test." "You should press the handheld button when you feel your baby move."
"You should press the handheld button when you feel your baby move." The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.
A nurse is assessing 4 newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn
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 providing teaching to a client who is at 40 weeks og gestation and has a new prescription for mistoprostol. Which of the following instructions should a nurse include in the teaching? A) "I can administer oxytocin 4 hours 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 minutes after the medication is inserted." D) "An antacid will be given 20 minutes prior to the insertion of the medication."
A) "I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.
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 the risk for vasoconstriction and possible abruptio placenta.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? A) Depression B) Polyuria C) Hypotension D) Urticaria
A) Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.
A nurse is caring for a client who is at 26 weeks of 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? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids.
Administer oxygen via a nonrebreather mask. When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus.
A nurse is providing edu about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aide the family's 7 year old into accepting the newborn? 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 does not feel left out and that they understand their role in the family.
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR.
Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.
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 caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies
To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.
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? "I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day."
"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 providing discharge teaching to a client who had a c-section 3 days ago. Which of the following instructions should the nurse include? "You can resume sexual activity in 1 week." "You won't need to do Kegel exercises since you had a cesarean." "You can still become pregnant if you are breastfeeding." "You are safe to start adding sit-ups to your exercise routine in 2 weeks."
"You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.
A nurse is admitting a client to the l&d unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring.
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 action the nurse should take.
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine
Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? Give the client orange juice. Elevate the client's legs. Have the client change position. Establish IV access.
Have the client change position. Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.
A nurse is reviewing the prenatal lab results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following lab findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 10,000/mm3 Platelets 250,000/mm3 Fasting blood glucose 90 mg/dL
Hemoglobin 10 g/dL A hemoglobin of 10 g/dL 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 assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum
Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.
The nurse is caring for a patient who has uterine atony and is experiencing postpartal hemorrhage. Which of the following actions is the nurse's priority? Check the client's capillary refill. Massage the client's fundus. Insert an indwelling urinary catheter for the client. Prepare the client for a blood transfusion.
Massage the client's fundus. Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? Fundal height 34 cm Report of decreased fetal movement Report of occasional ankle swelling BP 110/80 mm Hg
Report of decreased fetal movement The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress.
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? Lochia serosa vaginal drainage Vaginal pressure Intermittent vaginal pain Yellow exudate vaginal drainage
Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? ~clean the newborn's diaper area~wash the newborn's neck by lifting the newborn's chin~wipe the newborn's eyes from the inner canthus outward~wash the newborns legs and feet~cleanse the skin around the newborn's umbilical cord stump
~wipe the newborn's eyes from the inner canthis outward~wash the newborn's neck by lifting the newborn''s chin~cleanse the skin around the newborn's umbilical cord stump~wash the newborn's legs and feet~clean the newborn's diaper area The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening . Which of the following statements should the nurse include in the teaching? Obtain an informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes."
"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? "My sister will be able to carry my baby from the nursery to my room when she arrives." "The nurse will match my wrist band to my baby's crib card when they bring him to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when he's in my room."
"The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn.
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available ts 20g magnesium sulfate in 500ml of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many ml/hr? (round to whole number)
50 mL/hr
A nurse is a prenatal clinic is assessing a group of clients/ Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental aburption. 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 (L/S) ratio D) Maternal Alpha-fetoprotein (AFP)
A) Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative.
A nurse is observing a new parent caring for her 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 her 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 her 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 performing a PE of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect. (Select all that apply) Yellow sclera Acrocynosis Posterior fontanelle larger than anterior fontanelle Positive Babinski reflex Two umbilical arteries visible
Acrocynosis Positive Babinski reflex Two umbilical arteries visible Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet.Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel.Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age.Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.
A nurse is caring for a prenatal cleint who has parvovirus (5th's disease). Which of the following actions should the nurse take? A) Administer antiviral medication. B) Schedule an ultrasound examination. C) Administer Haemophilus influenzae type b vaccine. D) Schedule an indirect Coombs' test.
B) Schedule an ultrasound examination. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones
BUN 25 mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration.
A nurse is caring for a client who is at 36 weeks of gesation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test
Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.
A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells
Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.
A nurse is assessing client who has severe preenclampsia. Which of the following manifestations should the nurse expect? A) 2+ deep tendon reflexes B) Proteinuria of 200 mg in a 24-hr specimen C) Polyuria D) Blurred vision
D) Blurred vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
A nurse is caring for a client who is at 22 weeks gestation and is HIV positive. Which of the following actions should the nurse take? A) Administer penicillin G 2.4 million units IM to the client. B) Instruct the client to schedule an annual pelvic examination. C) Tell the client she will start medication for HIV immediately after delivery. D) Report the client's condition to the local health department.
D) Report the client's condition to the local health department. The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported.
*A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min
FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.
A nurse is performing a PE assessment on a newborn. Which of the following clinical findings should the nurse expect? (SATA) Heart rate 154/min Axillary temperature 36° C (96.8° F) Respiratory rate 58/min Length 43 cm (16.9 in) Weight 2,600 g (5 lb 12 oz)
Heart rate 154/min Respiratory rate 58/min Weight 2,600 g (5 lb 12 oz) Heart rate 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake.Axillary temperature 36° C (96.8° F) is incorrect. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F).Respiratory rate 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min.Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in).Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb).
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? Hypertension Hypothermia Constipation Muscle weakness
Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor
Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? Administer aspirin for pain. Maintain the client on bed rest. Massage the affected leg every 12 hr. Apply cold compresses to the affected calf.
Maintain the client on bed rest. The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds
Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. Restrict the total hourly intake to 200 mL. Monitor the FHR continuously. Administer protamine sulfate for manifestations of toxicity.
Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers?
Palpate fundus first Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas
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 in a provider's office is reviewing the med record of a client who is in the 1st trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preenclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus
Pregestational diabetes mellitus Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? Excessive bleeding Oligohydramnios Premature rupture of membranes Proteinuria
Premature rupture of membranes The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction.
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? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal.
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 developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash.
Remove all clothing from the newborn except the diaper The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin..
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? Report of visual disturbances Report of tingling of the fingers Report of urinary frequency Report of leg cramps
Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress
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 of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
A nurse is caring for a client who is at 30 weeks of 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? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed
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 transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record.
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 identification band to the information on the newborn's identification band.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions
Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.