Maternal Newborn ATI Final

A nurse is assessing a 2 day old newborn and notes an egg shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding?

A. This will resolve in 3 to 6 weeks without treatment B. This will resolve on its own within 3 to 4 days C.The provider might drain this area with syringe D. This appearance is expected at birth, so you don't need to worry A. This will resolve in 3 to 6 weeks without treatment This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks

A nurse is assessing a female client 24 hours after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take?

A. Administer a tocolytic medication B. Apply a heating pad to the mid-abdominal area C. Reassess the fundus in 2 hours D. Ambulate the client to the bathroom D. An increased fundal height in the postpartum period is a sign of non-contracted uterus, which increases the risk for hemorrhage. The most common postpartum cause of an elevated fundal height is an over-distended bladder

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching?

A. Drop by the clinic any day this week so we can count your babies kicks B. Count fetal kicks once a day for a total of 30 minutes C. Before bedtime is a good time to start counting the kicks D. Wear loose clothing when performing the kick count B. Before bedtime is a good time to start counting the kicks Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC) before bedtime or after meals for 2 hours or until 10 movements are counted, Alternatively the client can count all fetal movements in a 12 hour period each day until at least 10 movements are counted

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following?

A. Effacement B. Dilation C. Lightening D. Quickening C. Lightening Lightning describe the engagement of the fetal head into the pelvis. When this occurs, breathing becomes easier, but urination is more frequent

A nurse is teaching a client with pre-eclampsia who is schedule to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?

A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus B. Feeling of warmth The nurse should tell the client to expect a feeling of warmth all over her body while the magnesium sulfate is infusing

A nurse is teaching a parent how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching?

A. I should clean the circumcision site with half strength hydrogen peroxide twice a day B. I should apply the diaper loosely until the circumcision is healed C. I should notify the doctor if yellow discharge forms on the head of the penis D. Newborns typically do not experience any pain from this procedure B. I should apply the diaper loosely until circumcision is healed A loosely applied diaper will minimize pressure on the circumcision site, which will help decrease pain in the surgical area

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching?

A. I should consume about 700 extra calories a day while breastfeeding B. I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old C. I may notice increased cramping when I am feeding my baby D. I will place my baby on a strict feeding schedule to help establish a good feeding pattern C. I may notice increased cramping when I am feeding my baby The client may notice an increase in uterine cramping while breastfeeding due to the release of of oxytocin, which cause uterine muscle contraction

A nurse is providing teaching about home care to the parent of a newborn. Which of the following statements indicates an understanding of the teaching?

A. I should make sure the baby's bath water is between 115 and 120 degrees Fahrenheit B. I should let my baby sleep on the sofa until he is old enough to roll over C. I should ensure the airbag is functional when my baby is riding in the front seat of a car D. I should remove the bumper paf and stuffed toys from my babies crib D. The parent should remove bumper pads, stuffed toys and blankets from the babies crib to decrease the risk of suffocation and SIDs

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?

A. Instruct the client to pant during contractions B. Position the client supine with legs elevated C. Encourage the client to soak in a warm bath D. Apply pressure to the client's sacral area during contractions D. Apply pressure to the client's sacral area during contractions The nurse should provide counter pressure to the sacral area with a palm or firm object such as a tennis ball during contractions. Counter-pressure lifts the fetal head away from the sacral nerves, which decrease pain

A nurse is caring for a client who is experiencing prolonged labor. Which of the following fetal monitoring results indicates fetal compromise?

A. Baseline fetal heart rate of 110 to 130 per minute B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia D. Late decelerations with fetal bradycardia The nurse should identify that a fetal monitor showing recurrent late decelerations and bradycardia indicates that the fetus is not tolerating labor and might be compromised. These findings should be assessed in relation to the clinical picture of the progression of labor

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority?

A. Blood pressure 90/52 mmHg B. Ketones 2+ C. Specific gravity 1.035 D. Sodium 130mEq/L B. Ketones 2+ The greatest risk to this client is malnutrition that poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately.

A nurse is caring for a client who is in active labor and whose birth plan request only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation?

A. Breathing techniques B. Counter-pressure C. Biofeedback D. Use of a focal point B. Counter pressure The nurse should implement counter pressure as a non pharmacological cutaneous stimulation strategy. Other cutaneous stimulation include walking, effleurage, water therapy, and the application of heat or cold

A provider tells a client at 12 weeks gestation who practices Hinduism, that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse take?

A. Let's discuss other foods that are also high in protein that you could substitute for meat B. Eating meat during pregnancy provides necessary protein and does not cause miscarriage C. Why do you think that eating animal products will cause you to have a miscarriage D. Your doctor is recommending what is best for you and your baby A. Lets discuss other foods that are also high in protein that you could substitute for meat Many cultures have beliefs about food that the nurse should respect. Discussing non-animal protein sources can help the client identify foods that do not conflict with her religious and cultural beliefs.

A nurse is caring for a client who is 8 hour postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider (Select all that apply)

A. Massage the fundus B. Give oxygen at 2L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30 degrees A,C,D,E The nurse should massage the fundus to expel clots and help the uterus contract. The nurse should add oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30 degrees

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in teaching?

A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability C. Impaired placental perfusion Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impaired delivery of oxygen to the fetus

A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?

A. Perform a vaginal examination B. Perform continuous external fetal monitoring C. Insert a large bore IV catheter D. Obtain a blood sample for laboratory testing A. Perform a vaginal examination When a client has placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?

A. Place the unwrapped newborn on the mother's bare chest. B. Feed the infant 5 to 15 ml of 5% glucose water to assess the suck/swallow reflex C. Bathe the newborn under running warm water before feeding D. Administer vitamin K and eye prophylaxis prior to feeding A. Place the unwrapped newborn on the mother's bare chest Skin to skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors

A nurse is reviewing the electronic medical record for a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn?

A. Placenta previa B. Multiple gestation C. Infection D. Anemia C. Infection Blood group incompatibilities, maternal infection, maternal diabetes and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns

A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy?

A. Quickening B. Breast Tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate D. Auscultation of a fetal heart rate The auscultation of a fetal heart rate is a conclusive sign of pregnancy

A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?

A. Respirations 16/min B. Urinary output 40 ml in 2 hours C. Reflexes 2+ D. Fetal heart rate 158/min B. Urinary output 40ml in 2 hours Using the urgent verse nonurgent priority setting framework, the nurse should consider urgent needs to be the priority since they pose more of a threat to the client. As a result, the nurse should report the client's urinary output immediately. Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is <30ml/hr. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority setting framework and/or nursing knowledge to identify which finding is the most urgent

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 non pharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing D. Slow paced breathing Slow paced breathing is an easy technique for a client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In 2-3-4/Out 2-3-4 In 2-3-4/Out 2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation

A nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend?

A. Sip a carbonated beverage throughout the day B. Rock in a rocking chair C. Lie flat in bed with the legs extended D. Use a straw when drinking fluids B. Rock in a rocking chair The nurse should recommend that the client rocks in a rocking chair, ambulates in the hallway, and lies on her left side to assist with intestinal motility and to expel flatulence

The nurse is teaching a client who is postpartum about the rubella vaccine. Which of the following statements should the nurse include?

A. You must not take this medication if you've had chickenpox B. You must not become pregnant for 28 days after receiving this immunization C. You must not breastfeed because the virus is passed in breastmilk D. You must not receive other vaccines at the same time as the rubella vaccine B. You must not become pregnant for 28 days after receiving this immunization Clients must not become pregnant for 28 days following rubella immunization. They should be educated about the possible side effects and risk of teratogenic effects on the developing fetus

A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include?

A. You will need to wait 3 months before resuming sexual intercourse B. You don't need to use contraception C. As long as you will experience an overproduction of vaginal lubrication D. A reduction in sexual intercourse could indicate postpartum depression D. A reduction in sexual interest could indicate postpartum depression Manifestation of postpartum depression indicates decrease libido, feelings of sadness or anxiety, difficulty sleeping, or loss of appetite