NURS 3334. Exam 3 (ATI Exam E)

The clients last MP started on January 20. When is the clients expected delivery date?

October 27

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? a. 480 mL of urine output in 24 hours b. Blood pressure 144/92 mmHg c. +2 edema of the feet d. 1+ protein in urine

a. 480 mL of urine output in 24 hours

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? a. A newborn who is large for gestational age b. A newborn who has an Rh incompaitbility c. A newborn who has pathologic jaundice d. A newborn who has fetal alcohol syndrome

a. A newborn who is large for gestational age

A nurse is caring for a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? a. Betamethasone b. Nifedipine c. Indomethacin d. Verapamil

a. Betamethasone

A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. I can apply a heating pad to my back to relieve back pain b. I can have a low spinal block to help with labor pan c. I can have butorphanol every 2 hours during labor d. My time limit for staying in the hydrotherapy tub is 30 minutes

a. I can apply a heating pad to my back to relieve back pain

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require the administration of this medication? a. IV narcotics administered to the mother during labor b. Maternal drug use c. Hyaline membrane disease d. Meconium aspiration

a. IV narcotics administered to the mother during labor

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? SATA a. Magnesium sulfate infusion b. Distended bladder c. Oxytocin infusion d. Prolonged labor e. Small for gestational age newborn

a. Magnesium sulfate infusion b. Distended bladder d. Prolonged labor

A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying to provider? (SATA) a. Massage the fundus b. Give oxygen at 2 L/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. Massage the fundus 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 nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? a. The fundal height measures greater than gestational age b. A rigid abdomen is noted on palpation c. The client reports a pain level of 8 on a 0-to-10 pain scale d. A urine drug screen is positive for cocaine

a. The fundal height measures greater than gestational age

A nurse is teaching a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? a. These exercises should be done for 15 minutes each day to strengthen the perineal muscles b. Squatting exercises can tone your abdomen, helping you lose weight faster following delivery c. Practicing squatting exercises during pregnancy will reduce lower back pain during labor d. doing squatting exercises 3 times per week will improve your overall fitness

a. These exercises should be done for 15 minutes each day to strengthen the perineal muscles

A nurse is performing a physical assessment of a full term newborn and eliciting the moro reflex. Which of the following movements are expected responses to this reflex? Select all that apply. a. thumb and forefinger forming a "C" b. legs extending before pulling upward c. arms and legs adducting d. arms falling backward after startling e. head turning to the right

a. thumb and forefinger forming a "C" b. legs extending before pulling upward

A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? a. Review the medical record for a history of gastric bypass surgery b. Advise the client to start iron and vitamin C supplementation c. Review the medication list to determine if the client is taking an anticonvulsant d. request an order for sickle cell anemia screening

b. Advise the client to start iron and vitamin C supplementation

What order should a nurse use to massage a fundus? a. Rotate the upper hand to massage the client's uterus b. Ask the client to lie on her back with knees flexed c. Use slight downward pressure to compress the client's fundus d. Position the hand around the top of the client's fundus e. Place a hand just above the client's symphysis pubis

b. Ask the client to lie on her back with knees flexed e. Place a hand just above the client's symphysis pubis d. Position the hand around the top of the client's fundus a. Rotate the upper hand to massage the client's uterus c. Use slight downward pressure to compress the client's fundus

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? a. Overlapping suture lines b. Generalize petechiae c. Acrocyanosis d. Transient strabismus

b. Generalize petechiae

A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take? a. Instruct the client to stop pushing during contraction b. Inform the client that caput succedaneum resolves in a few days c. Monitor the newborn for decreased levels of bilirubin d. Identify that the newborn is at risk for facial palsy

b. Inform the client that caput succedaneum resolves in a few days

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? a. check for a full bladder b. Massage the fundus c. Measure vital signs d. Administer carboprostt IM

b. Massage the fundus

A nurse is providing teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include? a. Boil bottles and nipples for 20 minutes after each use b. Mix 1 scoop of powdered formula with 2 oz of water c. Store prepared bottles in the refrigerator for up to 4 days d. Warm formula by heating bottles in the microwave on the lowest setting

b. Mix 1 scoop of powdered formula with 2 oz of water

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? a. Gestational diabetes b. Preterm labor c. Inadequate milk supply d. Inadequate uterine growth

b. Preterm labor

A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about the potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include? a. The fibroid will shrink during pregnancy b. The fibroid can increase the risk of postpartum hemorrhage c. You will receive an injection of medroxyprogesterone acetate to shrink the fibroid d. you will have to undergo a cesarean birth because of the fibroid

b. The fibroid can increase the risk of postpartum hemorrhage

A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? a. It will take about 10 minutes to complete the test b. You might have to drink orange juice during the test c. During the test, you will be asked to massage your nipples d. During the test you will receive a medication to relax your uterus

b. You might have to drink orange juice during the test

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 the 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

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? a. A fetal stethoscope can first detect your baby's HR at 22 weeks b. After week 16, we can see if your baby is a boy or a girl c. A doppler device can detect your baby's HR at 12 weeks d. You will first feel the baby move at about 8 weeks

c. A doppler device can detect your baby's HR at 12 weeks

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? a. Heel creases over the entire sole of the foot b. Pendulous testes c. Extended extremities d. Leathery cracked skin

c. Extended extremities

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? a. Post-term birth b. Macrosomia c. Respiratory distress syndrome d. Maternal gestational diabetes

c. Respiratory distress syndrome

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? a. Continuous lochia flow and a flaccid uterus b. Report of increasing pain and pressure in the perineal area c. Slow trickle of bright vaginal bleeding and a firm fundus d. Gush of rubra lochia when the uterus is massaged

c. Slow trickle of bright vaginal bleeding and a firm fundus

A nurse is caring for a client who is scheduled to receive IV oxytocin for the induction of labor. The client has a Bishop score of 10. Which of the following findings should the nurse expect? a. The client will require dinoprostone for ripening of the cervix b. The client will experience lower back pain during labor c. The client will experience a successful induction of labor d. The client will require a vacuum of forceps assisted delivery

c. The client will experience a successful induction of labor

A nurse is providing nutritional teaching for a pregnant client who had a prepregnancy BMI of 38. Which of the following statements by the client demonstrate an understanding of the teaching about her recommended weight gain during pregnancy? a. I should plan to gain 12.7 to 18.1 kg during pregnancy b. I should plan to gain 11.3 to 15.9 kg during my pregnancy c. I should plan to gain 6.8 to 11.3 kg during my pregnancy d. I should plan to gain 5 to 9.1 kg during my pregnancy

d. I should plan to gain 5 to 9.1 kg during my pregnancy

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? a. I will limit breastfeeding to 5 minutes per breast b. I will not breastfeed if I start to have flu-like symptoms c. I will shop for an underwire nursing bra today d. I will avoid any of my family members who are ill

d. I will avoid any of my family members who are ill

A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? a. My ankles are swollen at the end of the day b. I can feel the baby kicking my ribs and it is very uncomfortable c. I'm growing more and more worried everyday d. My heart feels like it is racing

d. My heart feels like it is racing

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 nonpharmacological 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

A nurse is providing teaching about exercise to a client who is pregnant. Which of the following pieces of information should the nurse include? a. You can continue participating in whatever sports or activities you did prior to becoming pregnant b. Intermittent exercise is a great way to stay healthy during pregnancy c. You should limit your exercise to walking if you did not exercise prior to becoming pregnancy d. vigorous exercises should be limited and should not be preformed in hot humid weather

d. vigorous exercises should be limited and should not be preformed in hot humid weather