N261.ATIs
A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? Round the answer to the nearest whole number.
50 mL/hr
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? a. Acrocyanosis b. Transient strabismus c. Jaundice d. Caput succedaneum
c. 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.
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 hr following birth. c. Ambulate the client within 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 providing teaching to a client who is at 40 weeks of 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 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 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? a. Calcium gluconate b. Hydralazine c. Medroxyprogesterone acetate d. Methylergonovine
a. Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.
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? a. Cold cabbage leaves b. Purified lanolin cream c. A snug-fitting support bra d. Breast shells
a. 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 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? a. To estimate the fetal weight b. To locate a pocket of fluid c. To determine multiparity d. To prescreen for fetal anomalies
b. 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 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 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 charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following indicates the first step of Leopold maneuvers? a. The nurse faces the client's feet and uses the fingertips to palpate the cephalic prominence. This assessment allows the nurse to determine the attitude of the fetal head. b. The nurse determines which fetal part is presenting in the pelvic inlet. The nurse gently grasps the lower uterine segment between the thumb and forefingers, pressing in slightly. c. The nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. d. The nurse uses the palms of the hands to determine the location of the smooth fetal back and the irregularly shaped, smaller fetal parts.
c. 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 teaching a client who is at 10 weeks of 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 each day." b. "I should drink 2 liters of water each 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 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 for 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 a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? a. Singleton pregnancy b. BMI of 20 c. Maternal age 32 years d. Pregestational diabetes mellitus
d. 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 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? Exhibit 1: BP: 130/78 mm Hg RR: 20/min P: 90/min Exhibit 2: Diagnostic Results Hemoglobin 12 g/dL Hematocrit 34% 1-hr glucose tolerance test 120 mg/dL Exhibit 3: Progress Notes Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min
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 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? a. BUN 25 mg/dL b. Serum creatinine 0.8 mg/dL c. Urine output of 280 mL within 8 hr d. Urine negative for ketones
a. BUN 25 mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration.
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? a. Lochia serosa vaginal drainage 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 the blood that leaked into the tissues.
A nurse in a clinic is caring for a 16-year-old adolescent. Exhibit 1 History and Physical Adolescent is sexually active with two current partners. IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300: BP: 118/72 P: 100/min RR: 20/min T: 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300: Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis Cervical culture C-reactive protein Beta hCG Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding, specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process. Assessment Findings Abdominal pain Greenish discharge Diabetes Pain on urination Absence of condom use
Abdominal pain- gonorrhea Greenish discharge-gonorrhea, trichomoniasis Diabetes- candidiasis Pain on urination-trichomoniasis, gonorrhea, candidiasis Absence of condom use- trichomoniasis, gonorrhea
A nurse in a clinic is caring for a 16-year-old adolescent. Exhibit 1 History and Physical Adolescent is sexually active with two current partners. IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300: BP: 118/72 P; 100/min RR: 20/min T: 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300: Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis Cervical culture C-reactive protein Beta hCG Which of the following findings should the nurse report to the provider? Select all that apply. a. Abdominal assessment b. Vaginal discharge c. Heart rate d. Temperature e. Dyspareunia f. Condom usage
a. Abdominal assessment b. Vaginal discharge d. Temperature e. Dyspareunia f. Condom usage
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? a. Late decelerations b. Moderate variability of the 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 to the provider.
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? a. Minimal arm recoil b. Popliteal angle of 90° c. Creases over the entire foot sole d. Raised areolas with 3 to 4 mm buds
a. 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 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 identification band to the information on the newborn's identification band.
The nurse is reviewing laboratory results in the adolescent's medical record. Exhibit 1 History and Physical Adolescent is sexually active with two current partners. IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300: Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours. Reports painful urination and pain during sexual intercourse with minimal vaginal itching. Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300: BP: 18/72 P: 100/min RR: 20/min T: 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis Cervical culture C-reactive protein Beta hCG Exhibit 5 Diagnostic Results 1335: Urinalysis: Appearance clear (clear) Color amber yellow (amber yellow) pH 6.5 (4.6 to 8.0) Leukocyte esterase negative (negative) WBC count 0 (0 to 4) Nitrites none (none) Cervical culture pending C-reactive protein 12.2 mg/dL (<1.0 mg/dL) Beta hCG 3 IU/L negative (<5 IU/L) The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options: 1. The adolescent is most likely developing a. pelvic inflammatory disease b. ectopic pregnancy c. pyelonephritis 2. as evidenced by d. beta hcg level e. urinalysis f. c-reactive protein
a. pelvic inflammatory disease f. c-reactive protein Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection, including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending from the vagina.. Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore, the nurse should suspect the adolescent
Which of the following actions are the nurse's priorities? Select the 4 actions that the nurse should take immediately. Exhibit 1: Medical History Gravida 1, Para 0 41 weeks of gestation Induction of labor due to postdates Exhibit 2: Nurses' Notes 1400:Client received epidural anesthesia for reports of a pain level of 7 on a scale of 0 to 10 from uterine contractions. Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate. FHR: Baseline 135/min, average variability, accelerations present, no decelerations noted. Oxytocin infusing at 8 milliunit/min. Rate last increased by 2 milliunits/min at 1330. 1415: Client reports feeling light-headed. Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate FHR: Prolonged deceleration of fetal heart rate to 90/min, minimal variability. Exhibit 3: Vital Signs 1400: T 37.1° C (98.8° F) P 72/min RR 16/min BP 128/76 mm Hg SpO2 96% 1415: P 90/min RR 20/min BP 92/50 mm Hg SpO2 96% a. Assess cervical dilation. b. Administer a bolus of IV fluids. c. Insert an indwelling urinary catheter. d. Reposition the client to their side. e. Apply oxygen at 10 to 12 L/min by nonrebreather mask. f. Elevate the client's legs. g. Evaluate the client's pain level.
b. Administer a bolus of IV fluids. d. Reposition the client to their side. e. Apply oxygen at 10 to 12 L/min by nonrebreather mask. f. Elevate the client's legs. The nurse should plan to administer a bolus of IV fluids to increase the client's blood volume and improve uterine and intervillous space blood flow. The nurse should plan to turn the client to their side to increase cardiac output and improve uterine and intervillous space blood flow. The nurse should plan to administer oxygen via nonrebreather mask to increase maternal circulating oxygen levels and improve oxygen transfer through the intervillous spaces to the fetus. Elevating the client's legs will promote blood return to the heart and increase cardiac output. This action will improve uterine and intervillous space blood flow.
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? a. Determine progression of dilatation and 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 caring for a client who is pregnant in an antepartum clinic. Exhibit 1 Vital Signs 0900: T: 36.6° C (97.9° F) P: 88/min RR: 18/min BP: 130/70 SpO2: 97% on room air 1000: P: 76/min RR: 20/min BP: 138/68 SpO2: 98% on room air Exhibit 2 Medical History 0900: Gravida 3, Para 2 32 weeks of gestation Client reports cramping and lower back pain that started this morning. Client denies leaking fluid. Exhibit 3 Nurses' Notes 0900: Client placed on electronic fetal monitor. Client reports pain as 4 on a scale of 0 to 10. 1000: FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted. Uterine contractions occurring every 2 min, lasting 40 to 60 seconds in duration. Palpate as moderate intensity. Vaginal examination performed. Cervix is 2 cm dilated and 50% effaced. Which of the following findings should the nurse report to the provider? Select the 3 findings that should be reported. a. Maternal blood pressure b. Vaginal examination c. Gestational age d. Fetal heart rate e. Uterine contractions
b. Vaginal examination c. Gestational age e. Uterine contractions
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? a. clean the newborn's diaper area b. wash the newborn's neck by lifting the newborn's chin c. wipe the newborn's eyes from the inner canthus outward d. cleanse the skin around the newborn's umbilical cord stump e. wash the newborn's legs and feet
c, b, d, e, a 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 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? a. Blood pressure 136/88 mm Hg b. Report 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 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.
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? a. Deep tendon reflexes 4+ b. Fundal height 14 cm c. Urine protein 2+ d. FHR 152/min
d. 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.
