NURS402
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? (ATI MN p.107) A) "They are tablets administered vaginally." B) "They act by absorbing fluid from the tissues." C) "They promote dilation of the os." D) "They include an amniotomy."
A)
A nurse in a prenatal clinic is providing education to a client who is at 8 weeks of gestation. The client states, "I don't like milk." Which of the following foods should the nurse recommend as a good source of calcium? (ATI MN p.29) A) Dark leafy green vegetables B) Deep red or orange vegetables C) White breads and rice D) Meat, poultry, and fish
A)
A nurse in a provider's office is assessing a client who is at 35 weeks of gestation. The nurse should identify which of the following findings as the priority to report to the provider? A) Increasing intensity of uterine contractions B) Bilateral nonpitting ankle edema C) Report of burning sensation during urination D) Shortness of breath upon ambulation
A)
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? A) Vaginal intercourse can be resumed after 2 weeks. B) Products of conception will be present in vaginal bleeding C) Increased intake of zinc-rich foods is recommended D) Aspirin may be taken for cramps
A)
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunizations? A) Shortly after giving birth B) In the third trimester C) Immediately D) During her next attempt to get pregnant.
A)
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A) Palpable fetal movement B) Chadwick's sign C) Positive pregnancy test D) Amennorrhea
A)
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? (ATI MN p.144) A) Preeclampsia B) Thrombophlebitis C) Placenta previa D) Hyperemesis gravidarum
A)
A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe? (ATI MN p.57) A) Ceftriaxone B) Fluconazole C) Metronidazole D) Zidovudine
A)
A nurse is caring for a client who has mastitis. Which of the following is a typical causative agent of mastitis? (ATI MN p.150) A) Staphylococcus aureus B) Chlamydia trachomatis C) Klebsiella pneumonia D) Clostridium perfringens
A)
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? (ATI MN p.114) A) Hands and knees B) Lithotomy C) Trendelenberg D) Supine with a rolled towel under one hip
A)
A nurse is caring for a client who is in early labor and has a fetus in the occipitoposterior presentation. The client reports pain in their lower back with contractions. Which of the following pain management techniques is most likely to be effective in relieving low back pain caused by this type of fetal presentation? A) Counterpressure B) Effleurage C) Therapeutic touch D) Breathing techniques
A)
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? A) "You must be feeling scared and powerless." B) "Everyone worries about her baby when she's in labor." C) "Your pregnancy is advances so your baby should be fine." D) "We have a neonatal unit here that's equipped to handle emergencies."
A)
A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and a vaginal delivery is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? (ATI MN p.85) A) Pudendal B) Epidural C) Spinal D) Paracervical
A)
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? (ATI MN p.144) A) Increasing pulse and decreasing blood pressure B) Dizziness and increasing respiratory rate C) Cool, clammy skin and pale mucous membranes D) Altered mental status and level of consciousness
A)
A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include? (ATI MN p.25) A) Vaginal bleeding B) Swelling of the ankles C) Heartburn after eating D) Lightheadedness when lying on back
A)
A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? (ATI MN p.19) A) January 8 B) January 15 C) February 8 D) February 15
A)
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? (ATI MN p.202) A) Oxygen saturation B) Body temperature C) Serum bilirubin D) Heart rate
A)
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? (ATI MN p.135) A) "Apply cold compresses between feedings." B) "Take a warm shower right after feedings." C) "Apply breast milk to the nipples and allow them to air dry." D) "Use the various infant positions for feedings."
A)
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? (ATI MN p.126) A) Moderate lochia rubra B) Excessive lochia serosa C) Light lochia rubra D) Scant lochia serosa
A)
A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? (ATI MN p.174) A) "It assists with blood clotting." B) "It promotes maturation of the bowel." C) "It is a preventative vaccine." D) "It provides immunity."
A)
A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching? (ATI MN p.135) A) "Wear a supportive bra continuously for the first 72 hours." B) "Pump your breasts every 4 hours to relieve discomfort." C) "Use breast shells throughout the day to decrease milk supply." D) "Apply warm compresses until milk suppression occurs."
A)
A nurse is providing discharge teaching to a client who is 3 days postpartum and is formula feeding their newborn. Which of the following instructions should the nurse include when discussing engorgement? A) Apply ice packs to the breasts for 15 min to relieve swelling and discomfort B) Wear a loose-fitting bra for 1 week to minimize pressure on the breasts. C) Manually express small amounts of breastmilk three times per day D) Allow warm water from a shower to run over the breasts twice a day
A)
A nurse is teaching a client who is at 10 weeks of gestation about danger signs of pregnancy. The nurse should identify which of the following client statements as an indication of understanding? A) "I should report persistent vomiting that causes weight loss." B) "I should expect to develop hemorrhoids during my first trimester." C) "I know that breast pain means I have a breast infection." D) "I know that diarrhea is expected throughout my pregnancy."
A)
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? (ATI MN p.166) A) "This is more commonly seen in newborns who have dark skin." B) "This is a finding indicating hyperbilirubinemia." C) "This is a forceps mark from an operative delivery." D) "This is related to prolonged birth or trauma during delivery."
A)
Federal and state laws require that all newborns have prophylactic eye ointment placed in babies eyes to prevent: A) Blindness due to ophthalmia neonatorum B) The spread of disease to other babies in the nursery C) Congenital syphilis D) Conjunctivitis
A)
The umbilical cord is made up of 3 vessels. There are ______ and _________. A) 2 arteries and 1 vein B) 1 artery and 2 veins C) No arteries all veins D) All arteries and no veins
A)
Destruction of the neonate's erythrocytes results in: A) Jaundice B) Hemorrhage C) Anemia D) Infection
A) Because as RBC's are hemolyzed they become fragments of RBC's which results in jaundice. The amount of RBC;s at birth are higher than an adults but as they are no longer required, the body hemolyze them. Lowdermilk Chap. 23 Pg. 357-358
A nurse is caring for a client who is at 32 weeks of gestation and had placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? (ATI MN p.47) A) Betamethasone B) Indomethacin C) Nifedipine D) Methylergonovine
A) Given to promote lung maturity if delivery is anticipated
A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is this client experiencing? (ATI MN p.79) A) First stage, latent phase B) First stage, active phase C) First stage, transition phase D) Second stage of labor
A) In stage 1. latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds
A client with preeclampsia is receiving Magnesium sulfate IV for which of the following therapeutic effects? A) Seizure prophylaxis B) Decrease blood pressure C) Increase urine output D) Stop uterine contractions
A) Magnesium sulfate is given to preeclamptic clients to prevent seizures. It can decrease blood pressure but that is not the therapeutic use, other antihypertensives drugs such as labetolol and hydralazine are given to decrease blood pressure. Magnesium sulfate can stop uterine contractions but that is not the problem with preeclampsia.
When the Lochia has a foul odor, the nurse should: A) Realize that this indicates a possible endometritis B) Consider this to be normal for the first few days post birth C) Begin warm sitz baths to reduce the odor D) Discontinue showering until the odor goes away
A) One of the key signs of endometritis is foul lochia, with uterine tenderness, fever and chills. The nurse needs to contact provider for an antibiotic order stat. Endometritis can move to parametritis and peritonitis if the infection persists. This can lead to septic shock quickly. Lowdermilk Chap 34 Pg.834
A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate. Which of the following findings should the nurse identify as the cause for late decelerations? A) Uteroplacental insufficiency B) Fetal head compression C) Fetal ventricular septal defect D) Umbilical cord compression
A) Rationale:A late deceleration in the FHR is a nonreassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.
A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hr. Which of the following actions should the nurse take? A) Auscultate for a fetal heart rate. B) Have the client drink orange juice. C) Reassure the client that a term fetus is less active. D) Palpate the uterus for fetal movement.
A) Rationale:Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.
A nurse is caring for a client who is at 32wks and is experiencing preterm labor. which of the following medications should the nurse plan to administer? A) Betamethasone B) Misoprostol C) Methylergonovine D) Poractant alfa
A) Rationale:The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression.
A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A) Perform a vaginal examination B) Perform a continuous external fetal monitoring C) Insert a large-bore IV catheter D) Obtain a blood sample for laboratory testing
A) Rationale:When a client has a 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 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 urine output in 24 hr B) Blood pressure 144/92 mmHg C) +2 edema of the feet D) +1 protein in the urine
A) Rationale:When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.
A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? (ATI MN p15) A) "It is good to know that I won't have a tubal pregnancy in the future." B) "The doctor said that this surgery can affect my ability to get pregnant again." C) "I understand that one of my fallopian tubes had to be removed." D) "Ovulation can still occur because my ovaries were not affected."
A) The risk is increased
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? (ATI MN p.93) A) Assist the client into a left-lateral position B) Apply a fetal scalp electrode C) Insert an IV catheter D) Perform a vaginal exam
A) This increases uteroplacental perfusion
A Category II Fetal Heart Rate Classification is determined by the presence of: SATA A) Recurrent late decelerations on fetal strip B) Variable decelerations with other characteristics on fetal strip C) Early decelerations D) No decelerations seen on the strip only accelerations
A) B) Late decels are a sign of placental compromise while variable decels are found with cord compromise. Early decels are a benign finding indicating that delivery is near. Lowdermilk Chap. 18 Pg. 411. Box 18-1
A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? SATA (ATI MN p15) A) Occupation B) Menstrual history C) Childhood infectious diseases D) History of falls E) Recent blood transfusions
A) B) C)
A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? SATA (ATI MN p.38) A) Decreased fetal movement B) Intrauterine growth restriction C) Postmaturity D) Placenta previa E) Amniotic fluid emboli
A) B) C)
A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? SATA (ATI MN p.25) A) Breast tenderness B) Urinary frequency C) Epistaxis D) Dysuria E) Epigastric pain
A) B) C)
A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? SATA (ATI MN p.57) A) Gonorrhea B) Chlamydia C) HIV D) Group B streptococcus beta-hemolytic E) TORCH infection
A) B) C) D)
A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? SATA (ATI MN p.150) A) Epidural anesthesia B) Urinary bladder catheterization C) Frequent pelvic examinations D) History of UTIs E) Vaginal birth
A) B) C) D)
The nurse is caring for a client at 30 weeks gestation in preterm labor. Which of the following drugs would be indicated for this client? SATA a. Betamethasone b. Terbutaline c. Magnesium sulfate d. Nifedipine e. Indomethacin f. Labetolol
A) B) C) D) E) Betamethasone promotes fetal lung maturity in case the fetus delivers prematurely. Terbutaline, nifedipine, indomethacin, and magnesium sulfate are tocolytics that help to stop uterine contractions. Labetolol is used for severe hypertension.
A nurse is administering magnesium sulfate IV for seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? SATA (ATI MN p.64) A) Respirations less than 12/min B) Urinary output less than 25 mL/hr C) Hyperreflexic deep-tendon reflexes D) Decreased level of consciousness E) Flushing and sweating
A) B) D)
A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? SATA (ATI MN p.64) A) Diabetes B) Multifetal pregnancy C) Maternal age greater than 40 D) Gestational trophoblastic disease E) Oligohydramnios
A) B) D)
A nurse is caring for a client who is in active labor. The cervix is dilated to 5cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes an FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? SATA (ATI MN p.93) A) Moderate variability B) FHR accelerations C) FHR decelerations D) Normal baseline FHR E) Fetal tachycardia
A) B) D)
A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? SATA (ATI MN p.154) A) Fatigue B) Insomnia C) Euphoria D) Flat affect E) Delusions
A) B) D)
A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? SATA (ATI MN p.70) A) Urinary tract infections B) Multifetal pregnancy C) Oligohydramnios D) Diabetes mellitus E) Uterine abnormalities
A) B) D) E)
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? SATA (ATI MN p.131) A) Demonstrates apathy when the newborn cries B) Touches the newborn and maintains close physical proximity C) Views the newborn's behavior as uncooperative during diaper changing D) Identifies and relates newborn's characteristics to those of family members. E) Interprets the newborn's behavior as meaningful and a way of expressing needs.
A) C)
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? SATA (ATI MN p.202) A) Lanugo B) Long nails C) Weak grasp reflex D) Translucent skin E) Plump face
A) C) D)
A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? SATA (ATI MN p.70) A) Fetal distress B) Preterm labor C) Vaginal bleeding D) Cervical dilation greater than 6cm E) Severe gestational hypertension
A) C) D)
A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? SATA (ATI MN p.85) A) Encourage use of patterned breathing techniques B) Insert an indwelling urinary catheter C) Administer opioid analgesic medication. D) Suggest application of cold. E) Provide ice chips
A) C) D)
A nurse on the postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? SATA (ATI MN p.144) A) Calf tenderness to palpation B) Mottling of the affected extremity C) Elevated temperature D) Area of warmth E) Report of nausea
A) C) D)
Which of the following medications would the nurse expect to be ordered during a post-partum hemorrhage? (Select all that apply) A) Hemabate B) Magnesium Sulfate C) Cytotec D) Methergine E) Demerol
A) C) D) These medications will cause uterine contractions but in different ways so they can be used together in different combinations. Magnesium sulfate is incorrect and results in uterine relaxation as it is classified as a tocolytic. Demerol is incorrect because it is a pain medication and would have no effect on the hemorrhage. Lowdermilk Chap 34 Pg. 837
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? SATA (ATI MN p.144) A) Precipitous delivery B) Obesity C) Inversion of the uterus D) Oligohydramnios E) Retained placental fragments
A) C) E)
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? SATA (ATI MN p.57) A) Vacuum extractor B) Oxytocin infusion C) Forceps D) Cesarean birth E) Internal fetal monitoring
A) C) E)
A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? SATA (ATI MN p.126) A) Use a perineal squeeze bottle to cleanse the perineum. B) Sit on the perineum while resting in bed. C) Apply a topical anesthetic cream or spray to the perineum. D) Wipe the perineum thoroughly with a back-and-forth motion. E) Apply cold or ice packs to the perineum.
A) C) E)
A nurse is teaching about circumcision care to the parents of a newborn who was circumcised using the Gomco clamp method. Which of the following instructions should the nurse include? (SATA) A) Apply petroleum jelly to the penis with each diaper change for one week B) Cleanse the penis with warm water and mild soap twice a day C) Apply gentle pressure from a sterile gauze pad to control slight bleeding D) Gently remove and yellow exudate that forms on the circumcision site E) Apply the diaper loosely over the penis
A) C) E)
A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? SATA (ATI MN p.186) A) Hypospadias B) Hydrocele C) Family history of hemophilia D) Hyperbilirubinemia E) Epispadias
A) C) E) Hypospadias involve a defect in the location of the urethral opening and is a contraindication to circumcision. Epispadias involve a defect in the location of the urethral opening and is a contraindication to circumcision.
A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? SATA (ATI MN p.19) A) Client has delivered one newborn at term. B) Client has experienced no preterm labor. C) Client has been through active labor. D) Client has had two prior pregnancies. E) Client has one living child.
A) D) E)
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? SATA (ATI MN p.98) A) Lengthening of the umbilical cord B) Swift gush of clear amniotic fluid C) Softening of the lower uterine segment D) Appearance of dark blood from the vagina E) Fundus firm upon palpation
A) D) E)
A nurse is caring for a client who has been in labor for 12 hr with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of amniotomy? (ATI MN p.107) A) Fetal engagement B) Fetal lie C) Fetal attitude D) Fetal position
A) Prior to the performance of an amniotomy, it is imperative that the fetus is engaged at 0 station and at the level of the maternal ischial spines to prevent prolapse of the umbilical cord.
A nurse is teaching a client who is at 12 weeks of gestation about the manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching? A) Swelling of the face B) Urinary frequency C) White vaginal discharge D) Intermittent nausea
A) Rationale:The nurse should instruct the client to report swelling of the face because this can indicate a hypertensive disorder or preeclampsia.
A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A) Use vibroacoustic stimulation on the client's abdomen for 3 seconds B) Report the nonreactive test result to the provider immediately C) Request a prescription for an internal fetal scalp electrode D) Auscultate the FHR with a Doppler transducer
A) Rationale:The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.
A nurse is caring for a client who is 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion? SATA (ATI MN p.107) A) Oligohydramnios B) Hydramnios C) Fetal cord compression D) Hydration E) Fetal immaturity
A) C)
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following? (ATI MN p.47) A) Missed abortion B) Ectopic pregnancy C) Severe preeclampsia D) Hydatiform mole
B)
A nurse is assessing a newborn who was born 2 days ago. Which of the following findings should the nurse report to the provider? A) Blackening of the stump of the umbilical cord B) Redness of the skin at the base of the umbilical cord stump C) Scant amount of dried blood on the skin around the umbilical cord stump D) Hardening of the umbilical cord stump
B)
A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A) Place the client in the Trendelenberg position B) Apply pressure to the presenting part with the fingers C) Administer oxygen at 10L/min via a facemask D) Initiate IV fluids
B)
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? (ATI MN p.154) A) Reinforce the need to take antipsychotics as prescribed. B) Ask the client if they have thoughts of harming themselves of their infant. C) Monitor the infant for indications of failure to thrive. D) Review the client's medical record for history of bipolar disease.
B)
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year-old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? (ATI MN p.131) A) "Your son probably was not ready for toilet training and should wear training pants." B) "Your son is showing an adverse sibling response." C) "Your son may need counseling." D) "You should try sending your son to preschool to resolve the behavior."
B)
A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A) A male condom B) An intrauterine device (IUD) C) An oral contraceptive D) A diaphragm with spermicide
B)
A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? (ATI MN p.85) A) Abdominal effleurage B) Sacral counterpressure C) Showering if not contraindicated D) Back rub and massage
B)
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? (ATI MN p.114) A) Prolonged labor B) Reduced fetal oxygen supply C) Delayed cervical dilation D) Increased maternal stress
B)
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? (ATI MN p.38) A) Alpha-fetoprotein (AFP) B) Lecithin/sphingomyelin (L/S) ratio C) Kleihauer-Betke test D) Indirect Coombs' test
B)
A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? (ATI MN p.98) A) Assist the client to the bathroom B) Prepare for an impending delivery C) Prepare to remove a fecal impaction D) Encourage the client to take deep, cleansing breaths
B)
A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? (ATI MN p.70) A) Blood tinged sputum B) Dizziness C) Pallor D) Somnolence
B)
A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? (ATI MN p.181) A) Spits up clear mucus. B) Attempts to place their hand in their mouth. C) Turns the head towards sounds. D) Lies quietly with their eyes open.
B)
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications? A) Hearing loss B) Intrauterine growth restriction C) Type 1 diabetes mellitus D) Congenital heart defects
B)
A nurse is completing an admission assessment for a client who is at 39 weeks of gestation and reports fluid leaking from the vagina for two days. Which of the following conditions is the client at risk for developing? (ATI MN p.79) A) Cord prolapse B) Infection C) Postpartum hemorrhage D) Hydramnios
B)
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? (ATI MN p.93) A) Apply palms of both hands to sides of uterus B) Palpate the fundus of the uterus C) Grasp lower uterine segment between thumb and fingers D) Stand facing client's feet with fingertips outlining cephalic prominence.
B)
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? A) 3 cm above the umbilicus B) Slightly above the umbilicus C) Slightly below the umbilicus D) 3 cm below the umbilicus
B)
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? (ATI MN p.135) A) A client who has an episiotomy that is erythematous and has extended into a third-degree laceration B) A client who does not wash their hands between perineal care and breastfeeding C) A client who is not breastfeeding and is using measures to suppress lactation D) A client who has a caesarean incision that is well-approximated with no drainage.
B)
A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? A) "These exercises help prevent constipation." B) "These exercises help pelvic muscles to stretch during birth." C) "They can help reduce back aches." D) "They can help prevent further stretch marks."
B)
A nurse is providing teaching about breast feeding to a client who gave birth 8 hr ago. Which of the following information should the nurse include? A) The newborn should be fed 6 times in 24 hours. B) The newborn should have 6 wet diapers per day after day 4. C) The breasts will become engorged within 24 hrs of the first feeding. D) The newborn should be breastfed on a set schedule.
B)
A nurse is providing teaching about danger signs during pregnancy to a client who is at 20 weeks of gestation. The nurse should instruct the client to report headaches, blurred vision, and epigastric pain because these are indications of which of the following complications of pregnancy? A) Gestational diabetes B) Preeclampsia C) Hyperemesis gravidarum D) Abruptio placentae
B)
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? (ATI MN p.202) A) "The newborn will have decreased muscle tone." B) "The newborn will have a continuous, high-pitched cry." C) "The newborn will sleep for 2 to 3 hours after a feeding." D) "The newborn will have mild tremors when disturbed."
B)
A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as greatest risk for development of postpartum infection? (ATI MN p.150) A) A client who has experienced a precipitous labor less than 3 hr in duration. B) A client who had premature rupture of membranes and a prolonged labor. C) A client who delivered a large for gestation age infant. D) A client who had a boggy uterus that was not well-contracted.
B)
The 1st stage of labor begins with onset of hard contractions and ends with the birth of the baby. A) True B) False
B)
The contraction is measured in frequency, duration and strength. To find the frequency the nurse will measure: A) The beginning of the contraction to the end of the contraction B) The beginning of the contraction to the beginning of the next contraction C) From the end of the contraction to the beginning of the next contraction D) From the end of the contraction to the end of the next contraction
B)
The developing human is most vulnerable to teratogens during which time frame? A) After 12 weeks gestation B) In the embryonic stage C) At conception D) Near the end of the pregnancy
B)
The nurse assures that which of the following drugs is at the bedside of the client receiving magnesium sulfate? A) Glucagon B) Calcium gluconate C) Aluminum hydroxide D) Protamine sulfate
B)
When the nurse has assisted the provider with rupture of membranes (amniotomy), her first nursing action post rupture would be: A) Check the color, amount, odor and time the amniotomy took place. B) Assess the Fetal Heart Rate for possible prolapsed cord C) Get ready to deliver the baby as it will come faster now D) Go on a break since the baby should be born in a couple of hours
B)
Which STD would prevent the patient from a vaginal delivery when it is the most active? A) Human Papilloma Virus B) Herpes Simplex II C) Gonorrhea D) Yeast Infection
B)
Your client in her third trimester reports severe constipation. Which statement would you, as her nurse, respond with? A) "You should have a daily bowel movement and avoid straining." B) "You should consume extra fluids and eat a diet high in fiber and fruits." C) "You need to become accustomed to constipation it is a normal physiological response." D) "You should discontinue your iron supplement because it probably is the cause of your constipation."
B)
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? (ATI MN p.126) A) "I will need to use contraception for 3 months before considering pregnancy." B) "I need a second vaccination at my postpartum visit." C) "I was given the vaccine because my baby is O-positive." D) "I will be tested in 3 months to see if I have developed immunity."
B) A second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity.
A nurse is caring for a newborn who was born at 38 weeks of gestation, weights 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? (ATI MN p.166) A) Low birth weight B) Appropriate for gestational age C) Small for gestational age D) Large for gestational age
B) Appropriate between the 10th and 90th percentile
A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? A) Chvostek's sign B) Cullen's sign C) Chadwick's sign D) Goodell's sign
B) Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? (ATI MN p.107) A) Frequency of every 2 min B) Duration of 90 to 120 seconds C) Intensity of 60 to 90 mm Hg D) Resting tone of 15 mm Hg
B) Discontinue if more than 90sec
The nurse measures the fundal height of a pregnant client to help determine which of the following? A) Estimated fetal weight B) Fetal growth C) Preterm labor D) Fetal well-being
B) Fundal height is one indicator of fetal growth. It can also be a gross indicator of weeks gestation. The fundal height between 18 and 30 weeks gestation is approximately the same as weeks gestation (+/- 2 weeks gestation). A decreased fundal height can indicate IUGR where an increased fundal height can indicate multiple gestation or polyhydramnios.
A client with a diagnosis of preeclampsia includes hypertension and at least one other characteristic. Which of the following signs or symptoms are associated with preeclampsia? A) Neutropenia B) Proteinuria C) Hemodilution D) Seizure
B) Preeclampsia is defined as hypertension with proteinuria. It may be difficult to obtain a 24 hour urine to identify the proteinuria. So, in the absence of proteinuria, preeclampsia can still be diagnosed with hypertension and one of the following: thrombocytopenia, impaired liver function, new on-set renal insufficiency, pulmonary edema, new onset cerebral or visual disturbances. When seizures occur it is then identified as Eclampsia.
A nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A) Hypothermia B) Dark brown vaginal discharge C) Decreased urinary output D) Fetal heart tones
B) Rationale:A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A) Atrial septal defect B) Renal agenesis C) Spina bifida D) Hydrocephalus
B) Rationale:Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios.
A nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate? A) "You should drink 1 ounce of mineral oil every morning." B) "You should walk for at least 30 minutes every day." C) "You should eat at least 3 ounces of red meat per day." D) "You should stop taking your prenatal vitamin."
B) Rationale:The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.
A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect? A) Bradycardia B) Uterine contractions C) Seizures D) Bradypnea
B) Rationale:The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.
A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A) Perform a vaginal examination to determine cervical dilation. B) Obtain blood samples for baseline laboratory values. C) Place a spiral electrode on the fetal presenting part. D) Prepare the client for a transvaginal ultrasound.
B) Rationale:The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.
A nurse is teaching a client who is 8 weeks of gestation and has a uterine fibroid about the potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching? A) "The fibroid will shrink during the pregnancy." B) "The fibroid can increase the risk for 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) Rationale:Uterine fibroids can increase the risk for postpartum hemorrhage due to the increase in blood supply to the uterus, which supports the fibroid.
A postpartum client complains of a pain in her left leg. The first nursing action the nurse should take is to: A) Elevate her leg on pillows B) Test for a positive Homan's Sign C) Apply warm soaks to the leg D) Report her statement to the charge nurse.
B) The first action is always to assess then determine the next course of action in the nursing process. Homan's Sign is redness, swelling, pain, and warmth in the affected side. Lowdermilk Chap. 34 Pg. 832-833
A pregnant client at 35 weeks gestation complains of decreased fetal movement. Which of the following procedures should the nurse anticipate first? A) Biophysical Profile (BPP) B) Non stress test (NST) C) Contraction stress test (CST) D) Induction of labor
B) The first procedure would be a NST. If the NST is non-reactive then a CST or BPP might be ordered. If either of these procedures are abnormal then induction of labor might be scheduled.
A nurse is caring for a client who is at 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? (ATI MN p.79) A) Examine the amniotic fluid for meconium B) Check the FHR C) Dry the client and make them comfortable D) Apply a tocotransducer
B) The greatest risk to the client and fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. The first action to take is to check the FHR for clinical findings of distress.
A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? (ATI MN p.29) A) 1.8 kg (4 lb) weight gain and is in the first trimester B) 3.6 kg (8 lb) weight gain and is in the first trimester C) 6.8 kg (15 lb) weight gain and is in the second trimester D) 11.3 kg (25 lb) weight gain and is in the third trimester
B) They have exceeded the expected 3-4lb weight gain in the first trimester
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as a cause of the uterine atony? (ATI MN p.126) A) Poor involution B) Urinary retention C) Hemorrhage D) Infection
B) Urinary retention can result in a distention of the bladder. A distended bladder can cause uterine atony and lateral displacement from the midline.
A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? SATA (ATI MN p.19) A) Montgomery's glands B) Goodell's sign C) Ballottement D) Chadwick's sign E) Quickening
B) C) D) The other two are presumptive signs of pregnancy.
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? SATA (ATI MN p.154) A) Paranoia that their infant will be harmed B) Concerns about lack of income to pay bills C) Anxiety about assuming a new role as a parent D) Rapid decline in estrogen and progesterone E) Feeling of inadequacy with the new role as parent
B) C) D) E)
A nurse is providing care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? SATA (ATI MN p.47) A) Fetal position B) Blunt abdominal trauma C) Cocaine use D) Maternal age E) Cigarette smoking
B) C) E)
A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? SATA (ATI MN p.38) A) Fetal weight B) Fetal breathing movement C) Fetal tone D) Fetal position E) Amniotic fluid volume
B) C) E)
A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? SATA a. oxytocin infusion b. prolonged labor c. magnesium sulfate infusion d. small for gestational age newborn e. distended bladder
B) C) E) b. prolonged labor--can stretch out the musculature of the uterus & cause fatigue, which prevents the uterus from contracting c. mag sulfate infusion--smooth muscle relaxant & can prevent adequate contraction of uterus. e. distended bladder--pt can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. the distended bladder displaces the uterus & can prevent adequate contraction of the uterus
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? SATA (ATI MN p.93) A) "It is considered a noninvasive procedure." B) "It can detect abnormal fetal heart tones early." C) "It can determine the amount of amniotic fluid you have." D) "It allows for accurate readings with maternal movement." E) "It can measure uterine contraction intensity."
B) D) E)
When assessing a patient's lochia and finding it dark red on the 3rd postpartum day, the nurse would consider A) This to be an abnormal finding B) This to a normal finding C) This to be something to report to the provider D) This to be an emergency situation
B) By the third day the Lochia will still be Rubra which last from 3-4 days. Lochia Serosa will begin next but some dark red Lochia can continue for a few more days without concern. Lowdermilk Chap. 20 Pg. 478-480
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4C (97.6F). Which of the following is the priority nursing action? A) Insert an indwelling urinary catheter. B) Initiate IV access C) Witness the signature for informed consent for surgery. D) Prepare the abdominal and perineal areas.
B) Client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.
If the fundus of the postpartum client is boggy and off midline, the first nursing action should be:__________________________. A) To take the patient's blood pressure B) To empty her bladder then reassess C) To call her doctor and report this finding D) To do nothing as this is a normal finding
B) Number one reason for off midline and boggy uterus is a full bladder. This is the first action with remassaging and reassessing once the bladder is empty. If the uterus remains boggy or Lochia continues to be heavy the nurse will alert the provider and take the BP. Lowdermilk Chap. 20 Pg. 478
Quickening is the term used to describe: A) Increased size of the pregnant uterus B) Fetal movements first felt by the mother C) Color changes of the cervix D) Increase in the blood flow to the placenta
B) Quickening is the first movement reported by the mom. In a primigravida this is usually by the 18-20th week but in a multigravida it may be as early as 14-16 weeks.
A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching? A) "You will have a nonstress test prior to the ultrasound." B) "You will need to have a full bladder during the ultrasound." C) "The ultrasound will determine the length of your cervix." D) "You will experience uterine cramping during the ultrasound."
B) Rationale:The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about the 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) Rationale:The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing.
A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? (ATI MN p15) A) A client whose sister has alopecia B) A client whose partner has von Willebrand disease C) A client who has an allergy to sulfa D) A client who had rubella 3 months ago
B) von Willebrand disease is a genetic bleeding disorder and warrants a client being referred to a genetic counselor
A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? (ATI MN p.19) A) "This is due to an increase in blood volume." B) "This is due to pressure from the uterus on the diaphragm." C) "This is due to the weight of the uterus on the vena cava." D) "This is due to increased cardiac output."
C)
A nurse in a provider's office is caring for a client who is at 36 weeks gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? A) "This will determine if there is more than one fetus." B) "It is useful for estimating fetal age." C) "It assists in identifying the location of the placenta and fetus." D) "This is a screening tool for spina bifida."
C)
A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse identify as a potential danger sign of pregnancy? A) Angiomas on the face B) Supine hypotension C) Glycosuria D) Leukorrhea
C)
A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse expect? a. temp of one leg differing from that of the other b. symmetrical gluteal folds c. limited abduction of one hip d. legs that are shorter than the arms
C)
A nurse is assessing the fundal height for a client who is at 28 weeks of gestation. The nurse should measure the distance in centimeters between which two anatomical landmarks? A) The mons pubis and the xiphoid process B) The top of the fundus and the umbilicus C) The symphysis pubis and the top of the fundus D) The mons pubis and the umbilicus
C)
A nurse is caring for a client and partner during the second stage of labor. The client's partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make? (ATI MN p.98) A) "The placenta will protrude from the vagina." B) "Your partner will report a decrease in the intensity of contractions." C) "The vaginal area will bulge as the baby's head appears." D) "Your partner will report less rectal pressure."
C)
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? (ATI MN p.85) A) "It is needed to promote increased urine output." B) "It is needed to counteract respiratory depression." C) "It is needed to counteract hypotension." D) "It is needed to prevent oligohydramnios."
C)
A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version? (ATI MN p.107) A) Prostaglandin gel B) Magnesium sulfate C) Rho(D) immune globulin D) Oxytocin
C)
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? (ATI MN p.114) A) Intrauterine growth restriction B) Hyperglycemia C) Meconium aspiration D) Polyhydramnios
C)
A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A) "This will occur during the last trimester of pregnancy." B) "This will happen by the end of the first trimester of pregnancy." C) "This will occur between the fourth and fifth months of pregnancy." D) "This will happen once the uterus begins to rise out of the pelvis."
C)
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform. A) Immediately report the situation to the client's provider and prepare the client for induction of labor. B) Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. C) Offer the client a snack of orange juice and crackers. D) Turn the client onto her left side.
C)
A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement? (ATI MN p.186) A) Apply Gelfoam powder to the site. B) Place the newborn in the prone position. C) Apply petroleum gauze to the site. D) Avoid changing the diaper until the first voiding.
C)
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? (ATI MN p.202) A) Conjunctivitis B) Bronze skin discoloration C) Sunken fontanels D) Maculopapular skin rash
C)
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching. A) Limit alcohol consumption B) Increase intake of iron-rich foods C) Consume foods fortified with folic acid. D) Avoid foods containing aspartame.
C)
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? (ATI MN p.174) A) Oflaxacin B) Nystatin C) Erythromycin D) Ceftriaxone
C)
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? (ATI MN p.135) A) Scant, non-odorous white vaginal discharge B) Uterine cramping during breastfeeding C) Sore nipple with cracks and fissures D) Decreased response with sexual activity
C)
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? (ATI MN p.135) A) Sit-ups B) Pelvic tilt exercises C) Kegel exercises D) Abdominal crunches
C)
A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? (ATI MN p.186) A) "The circumcision will heal within a couple of days." B) "I should remove the yellow mucus that will form." C) "I will clean the penis with each diaper change." D) "I will give him a tub bath within a couple of days."
C)
A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? (ATI MN p.64) A) "I will take this pill with my breakfast." B) "I will take this medication with a glass of milk." C) "I plan to drink more orange juice while taking this pill." D) "I plan to add more calcium-rich foods to my diet while taking this medication."
C)
A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? (ATI MN p.186) A) Front seat, rear-facing B) Front seat, forward-facing C) Back seat, rear-facing D) Back seat, forward-facing
C)
A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? (ATI MN p.174) A) Ask the parent to state their full name. B) Look at the name on the newborn's bassinet. C) Match the parent's identification band with the newborn's band. D) Compare name on the bassinet and room number.
C)
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? (ATI MN p.150) A) "Limit the amount of time the infant nurses on each breast." B) "Nurse the infant only on the unaffected breast until resolved." C) "Completely empty each breast at each feeding or use a pump." D) "Wear a tight-fitting bra until lactation has ceased."
C)
A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? (ATI MN p.38) A) "You will lay on your right side during the procedure." B) "You should not eat anything for 24 hours prior to the procedure." C) "You should empty your bladder prior to the procedure." D) "The test is done to determine gestational age."
C)
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? (ATI MN p.181) A) Burp the newborn at the end of the feeding. B) Hold the newborn close in a supine position. C) Keep the nipple full of formula throughout the feeding. D) Refrigerate any unused formula.
C)
A nurse is teaching the parents of a newborn about bathing techniques. Which of the following instructions should the nurse include? A) Bathe the newborn once per day B) Bathe the newborn after a feeding C) Clean the newborns face first using plain water D) Clean the newborn's ears and nose with cotton swabs
C)
In the four stages of labor the 3rd stage is: A) From the first true contraction to complete dilation of the cervix B) From complete dilation of the cervix to the delivery of the baby C) From the birth of the baby to the birth of the placenta D) For 2 hours following the expulsion of the placenta
C)
PICA is a term used for a pregnant client who: A) Experiences intense itching all over her body B) Is depressed and feels suicidal C) Eats or craves non-nutritive food sources like dirt, laundry starch D) Has a dark mask on cheeks that gets worse in sunlight
C)
The appropriate weight gain for a woman during her pregnancy with a normal BMI would be: A) 10-15 lb B) 6-20 lb C) 25-35 lb D) 21-25 lb
C)
The nurse instructs the client with a molar pregnancy to prevent pregnancy for at least one year. Why should the nurse instruct this client about preventing pregnancy? A) The client needs adequate time to recover after a traumatic pregnancy. B) Molar pregnancies are too emotional for clients to handle another pregnancy so quickly. C) It would be difficult to determine if the presence of hCG (human chorionic gonadotropin) is from pregnancy or cancer. D) The client is at a greater risk of having another molar pregnancy within one year of a previous molar pregnancy.
C)
The nurse should educate all newly diagnosed gestational diabetic clients about which of the following? A) Subcutaneous injection of insulin B) Postpartum tubal ligation C) Fingerstick glucose D) Cesarean delivery
C)
The purpose of molding of the newborn head during birth: A) Is to allow for increased pressure of the spinal fluid B) Protect the brain from intrauterine pressure C) To allow the head to pass through the birth canal D) To permit easy adjustment to the atmospheric pressure
C)
Vitamin K is administered to the newborn at birth to prevent hemorrhage. This is necessary because: A) The mother's supply of vitamin K was depleted in labor B) The immature liver is unable to produce Vitamin K C) The neonate's intestines have insufficient flora to produce Vitamin K D) Many hazardous situations can place the neonate at jeopardy for hemorrhage
C)
When testing for pregnancy with a urine sample, the test will become positive in the presence of which hormone? A) Progesterone B) hPL C) hCG D) Estrogen
C)
A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretation of this finding should the nurse make? A) There is evidence of cervical incompetence B) There is no evidence of two or more accelerations in fetal heart rate in 20 min C) There is no evidence of uteroplacental insufficiency D) There are less than 3 uterine contractions in a 10-min period
C) A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations.
Which of the following tests is done to screen and diagnose gestational diabetes? A) Group Beta Strep B) Indirect Coombs C) Glucose Tolerance Test D) Fasting blood sugar
C) A one hour GTT (glucose tolerance test) is done around 28 weeks gestation to screen for gestational diabetes. A 3 hour GTT is done if the one hour GTT was abnormal (typically greater than 140-145). The 3 hour GTT is diagnostic of gestational diabetes.
A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? (ATI MN p15) A) "You will need to see a genetic counselor as part of the assessment." B) "It is usually the female who is having trouble, so the male doesn't have to be involved." C) "The male is the easiest to assess, and the provider will usually begin there." D) "Think about adopting first because there are many babies that need good homes."
C) A sperm analysis is one of the first steps in the infertility assessment process and can identify a cause of infertility in a less invasive and costly manner
Symptoms of a placentae abruptio include all of the following except: A) Dark red painful bleeding B) Fetal distress C) Bright red painless bleeding D) Ridged painful uterus
C) An abruption can be large or small but presents with dark red painful bleeding, fetal distress, and a board-like painful uterus to palpation. This is different from the placenta previa which shows as bright red painless bleeding.
One of the chief concerns about Premature Rupture of Membranes is: A) A "dry" birth B) A paralytic ileus in the newborn C) Chorioamnionitis D) A urinary tract infection
C) As rupture of the bag of waters allows vaginal bacteria to travel up into the previously sterile environment of the uterus. PROM has no bearing on paralytic ileus, a dry birth is a misnomer as fluid continues to be produced until delivery, PROM does not lead to a urinary infection as the fluid is sterile when released. Lowdermilk Chap. 32 p. 771
There are two types of post-partum hemorrhage; early and late. (PPH). The primary cause of the early hemorrhage would probably be: A) Retained placental fragments B ) Urinary infection C) Uterine atony D) Fatigue
C) Early hemorrhage occurs in the first 24 hours whereas Late PPH is from 24 hours to 6 weeks. Early is usually the uterus that will not contract from multiples, high parity, long labor, high dosage Pitocin etc. Lowdermilk Chap. 34 Pg.825
A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss? (ATI MN p.174) A) Conduction B) Convection C) Evaporation D) Radiation
C) Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In a newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from the skin.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? (ATI MN p.126) a. Evidence of a possible vaginal hematoma b. An indication of a cervical or perineal laceration c. A normal postural discharge of lochia d. Abnormally excessive lochia rubra flow
C) Lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. Massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.
The nurse starts to perform Leopold Maneuvers on a pregnant client prior to applying the electronic fetal monitor. What is the main reason for doing Leopold Maneuvers at this time? A) To identify the presentation of the fetus B) To determine the need for internal monitors C) To locate the fetal back D) To feel for fetal movements
C) Prior to applying electronic fetal monitors, the nurse wants to locate the fetal back to know where to apply the monitor. The fetal back is the ideal place pick up the fetal heart rate. Leopold maneuvers can identify fetal presentation (what part is presenting first), fetal lie, and position. It can also determine whether the presenting part is flexed or extended, engaged, or free floating.
A nurse is teaching a client who is 13 weeks of gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching? A) "I am sad that I won't be able to get pregnant again." B) "I can resume having sex as soon as I feel up to it." C) "I should go to the hospital if I think I may be in labor." D) "I should expect bright red bleeding while the cerclage is in place."
C) Rationale:Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.
A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A) Blood pressure B) Intake and output C) Daily weight D) Severity of edema
C) Rationale:Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status.
A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider? A) Deep tendon reflexes 2+ B) Blood pressure 150/96 mmHg C) Urinary output 20 mL/hr D) Respiratory rate 16/min
C) Rationale:The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.
A nurse is reviewing laboratory results for a client who is 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type of O negative. Which of the following actions should the nurse take? A) Administer a dose of Rh(D) immune globulin B) Request a prescription for an antibiotic until delivery C) Instruct the client to obtain a rubella immunization after delivery D) Inform the client that she will need to deliver via cesarean birth
C) Rationale:This client is not immune to rubella and should receive this immunization after delivery.
A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A) Mild constipation B) Nasal congestion C) Vaginal bleeding D) 10 fetal movements per hour
C) Rationale:Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.
The nurse gives a pregnant client at 28 weeks gestation an injection of Rhogam for which of the following reasons? A) To protect the fetus from Rh antigens. B) To prevent the fetus from forming Rh antibodies. C) To prevent the client from developing Rh antibodies. D) To prevent complications with her current pregnancy.
C) Rhogam prevents the Rh negative client from developing Rh antibodies to the Rh factor. By preventing the formation of antibodies, it will protect the next Rh positive fetus' red blood cells from being attacked.
A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough, I can't do this anymore." Which of the following stages of labor is the client experiencing? (ATI MN p.79) A) Second stage B) Fourth stage C) Transition phase D) Latent phase
C) The transition phase of labor occurs when the client becomes irritable, feels rectal pressure similar to the need to have a bowel movement, and can become nauseous with emesis.
The patient complains of a watery yellowish fluid leaking from her nipples. The nurse explains that this fluid: A) Is called foremilk and will get heavier in the next week B) Is what breast milk looks like C) Is called colostrum and last a few days D) Is indicative of infection and she will need an antibiotic
C) The yellowish fluid is colostrum which contains immune properties and other healthy benefits for the infant and should be encouraged. It is not foremilk or infectious. Many Hispanic women will refuse to breast feed until colostrum goes away as they feel that it is infected milk. Lowdermilk Chap 25 Pg. 607
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? A). apply barrier ointment to the newborn's perianal region B). offer the newborn glucose water between feedings C). use a photometer to monitor the lamp's energy D). keep the newborn's eye patches on during feedings
C) the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? SATA (ATI MN p.166) A) Expiratory grunting B) Inspiratory nasal flaring C) Apnea for 10-second periods D) Obligatory nose breathing E) Crackles and wheezing
C) D)
A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? SATA (ATI MN p.25) A) Avoid any lifting B) Perform Kegel exercises twice a day C) Perform the pelvic rock exercise every day D) Use proper body mechanics E) Avoid constrictive clothing
C) D)
A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? SATA (ATI MN p.181) A) Use a disinfectant wipe to clean the lid of the formula can. B) Store prepared formula in the refrigerator for up to 72 hours. C) Place used bottles in the dishwasher. D) Check the nipple for appropriate flow of formula. E) Use tap water to dilute concentrated formula.
C) D) E)
A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? SATA (ATI MN p.150) A) "I will perform perineal care and apply a perineal pad in a back-to-front direction." B) "I will drink grape juice to make my urine more acidic." C) "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D) "I will go back to breastfeeding after I have finished taking the antibiotic." E) "I will take Tylenol for any discomfort."
C) E)
A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following action should the nurse take? A) Prepare the client for an ultrasound examination. B) Prepare the client for an emergency cesarean birth C) Prepare equipment needed for newborn resuscitation D) Perform endotracheal suctioning as soon as the fetal head is delivered
C) Rationale:The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.
A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client? (ATI MN p.19) A) "You should wait until 4 weeks after conception to be tested." B) "You should be off any medications for 24 hours prior to the test." C) "You should be NPO for at least 8 hours prior to the test." D) "You should collect urine from the first morning void."
D)
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A) "It's a minor inconvenience, which you should ignore." B) "In most cases it only lasts until the 12th week, but will continue if you have poor bladder tone." C) "There is no way to predict how long it will last in each individual client." D) "It occurs during the first trimester and near the end of the pregnancy."
D)
A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? (ATI MN p.131) A) Encourage the parents to touch and explore the neonate's features. B) Limit noise and interruption in the delivery room. C) Place the neonate at the client's breast. D) Position the neonate skin-to-skin on the client's chest.
D)
A nurse is assessing a client who is in her third trimester of pregnancy. When assessing for indications of preeclampsia, the nurse should ask the client if she has which of the following manifestations? A) Pelvic pressure B) Vaginal bleeding C) Leg cramps D) Blurred vision
D)
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? (ATI MN p.154) A) Postpartum fatigue B) Postpartum psychosis C) Letting-go phase D) Postpartum blues
D)
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? (ATI MN p.166) A) Hold the newborn vertically under arms and allow one foot to touch table B) Stimulate the pads of the newborn's hands with stroking or massage C) Stimulate the soles of the newborn's feet on the outer lateral surface of each foot D) Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backwards
D)
A nurse is caring for a client who is at 42 weeks gestation and in labor. The client ask the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? (ATI MN p.202) A) "Your baby will have excess body fat." B) "Your baby will have flat areola without breast buds." C) "Your baby's heels will easily move to his ears." D) "Your baby's skin will have a leathery appearance."
D)
A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? (ATI MN p.47) A) No alteration in menses B) Transvaginal ultrasound indicating a fetus in the uterus C) Blood progesterone greater than the expected reference range D) Report of severe shoulder pain
D)
A nurse is caring for a client who is getting patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? (ATI MN p.85) A) Administer oxygen via nasal cannula at 2 L/min B) Apply a warm blanket C) Assist the client to a side-lying position D) Place an oxygen mask over the client's nose and mouth
D)
A nurse is caring for a client who is in labor. with the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? (ATI MN p.114) A) Precipitous labor B) Premature rupture of membranes C) Postmaturity syndrome D) Prolapsed umbilical cord
D)
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? A) Headaches B) Nervousness C) Tremors D) Dyspnea
D)
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? (ATI MN p.98) A) "A full bladder increases the risk for fetal trauma." B) "A full bladder increases the risk for bladder infections." C) "A distended bladder will be traumatized by frequent pelvic exams." D) "A distended bladder reduces pelvic space needed for birth."
D)
A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? (ATI MN p.38) A) "It is used to stimulate uterine contractions." B) "It will decrease the incidence of uterine contractions." C) "It lulls the fetus to sleep." D) "It awakens a sleeping fetus."
D)
A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? (ATI MN p.64) A) Nifedipine B) Pyridoxine C) Ferrous sulfate D) Calcium gluconate
D)
A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? A) The test assesses fetal lung maturity. B) It assesses various markers of fetal well-being. C) This test identifies an Rh incompatibility between the mother and fetus. D) It is a screening test for spinal defects in the fetus.
D)
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? (ATI MN p.174) A) Initiating breastfeeding B) Performing the initial bath C) Giving a Vitamin K injection D) Covering the newborn's head with a cap
D)
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborns mouth. This finding is a characteristic of which of the following conditions? (ATI MN p.166) A) Mongolian spots B) Milia spots C) Erythema toxicum D) Epstein's pearls
D)
A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates understanding of the teaching? (ATI MN p.181) A) The parent places a few drops of water on their nipple before feeding. B) The parent gently removes their nipple from the infant's mouth to break the suction. C) When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger. D) When latched on, the infant's nose, chin, and cheek are touching the breast.
D)
A nurse is performing a gestational age assessment using the New Ballard Score. Which of the following findings should indicate to the nurse that the newborn is preterm? A) Flexion of the extremities at rest. B) Creases over the entire plantar surface C) Leathery skin D) Flat areola
D)
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? (ATI MN p.144) A) Apply cold compresses to the affected extremity B) Massage the affected extremity C) Allow the client to ambulate D) Measure leg circumferences
D)
A nurse is providing care of a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? (ATI MN p.70) A) Calcium gluconate B) Indomethacin C) Nifedipine D) Betamethasone
D)
A nurse is reviewing a new prescription for iron supplements with a client who is at 8 weeks of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? (ATI MN p.29) A) Ice water B) Low fat or while milk C) Tea or coffee D) Orange juice
D)
A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? (ATI MN p.181) A) Over-the-shoulder B) Supine C) Chin-supported D) Cradle
D)
A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? (ATI MN p.186) A) Cover the cord with a small gauze square. B) Trickle clean water over the cord with each diaper change. C) Apply hydrogen peroxide to the cord twice a day. D) Keep the diaper folded below the cord.
D)
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? (ATI MN p.93) A) Peak of the uterine contraction B) Moderate variability C) FHR acceleration D) Relaxation between uterine contractions
D)
A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? (ATI MN p.57) A) "Obtain an immunization against rubella early in pregnancy." B) "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." C) "A client should avoid crowded places during pregnancy." D) "A client should avoid consuming undercooked meat while pregnant."
D)
A woman, who is being seen in the prenatal clinic, complains of moderate nausea and vomiting every morning. She asks for the nurse's advice on how to deal with it so she can go to work. The nurse's best answer would include: A) High protein low carb diet B) Avoid salty foods C) Increased fluid intake when nauseated D) Small frequent light meals throughout day
D)
Which substance is an antidote for magnesium sulfate toxicity? A) Protamine sulfate B) Vitamin K C) Naloxone D) Calcium gluconate
D)
A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? A) Monitor vaginal bleeding B) Administer glucocorticoids C) Insert an IV catheter D) Apply an external fetal monitor
D) Based on Maslow's hierarchy of needs, the nurse should apply the fetal monitor to determine if the fetus is in distress
A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1-2 hr of delivery? a. poractant alpha b. rotavirus immunization c. naloxone d. erythromycin ophthalmic ointment
D) Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth.
The term "involution" refers to: A) An increase in the size of the fetus as it grows B) A sloughing off of the inner lining of the uterus C) A discharge of the ovum from the Graafian follicle D) The return of the uterus to its non-pregnant state
D) Involution is the process of returning to the pre-pregnancy uterine shape though somewhat larger each pregnancy. Subinvolution is when the pattern of return is not the normal 1-2 cm/day x 2 weeks. Lowdermilk Chap. 2o Pg. 478
A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? (ATI MN p.98) A) Inspect the introitus for a prolapsed cord B) Perform a test to identify the ferning pattern C) Monitor station of the presenting part D) Defer vaginal examinations
D) Need to rule out placenta previa or abruptio placentae first
A nurse is providing teaching to a client who is at 8 weeks of gestation about the manifestations to report to the provider during pregnancy. Which of the following information should the nurse include in the teaching? A) Nausea upon awakening B) Leg cramps when sleeping C) Increase in white vaginal discharge D) Blurred or double vision
D) Rationale:A client who is pregnant should report experiencing blurred or double vision as these could be a manifestation of gestation hypertension or pre-eclampsia.
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following lab tests will be used to confirm her pregnancy? A) A blood test for the presence of estrogen B) A blood test for the amount of circulating progesterone C) A urine test for the presence of human chorionic somatomammotropin D) A urine test for the presence of human chorionic gonadotropin
D) Rationale:Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing.
A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which of the following findings should the nurse expect? A) Fundal height of 34 cm (13.4 in) B) Total pregnancy weight gain of 3.6 kg (8 lb) C) Gestational hypertension D) Fetal gastrointestinal anomaly
D) Rationale:Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.
A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of the following findings should the nurse expect? A) Increased platelet count B) Fetal distress C) Decreased urinary output D) Dark red vaginal bleeding
D) Rationale:The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.
The lochia is an indicator of the rate of healing of the uterus. Choose the correct pattern of lochia for a normal postpartum woman: A) Rubra ,alba, serosa B) Serosa, rubra, alba C) Alba, rubra, serosa D) Rubra, serosa, alba
D) Rubra 1-3 days alba 4-10 days and ends with Alba 10 days to 3-4 weeks. Lowdermilk Chap 20 Pg. 479
A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? A) Assess deep tendon reflexes every hour. B) Obtain a daily weight. C) Continuous fetal monitoring. D) Ambulate twice daily.
D) The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental flow.
The causative organism for mastitis is usually: A) Pseudomonas B) E. Coli C) Streptococcus D) Staphylococcus
D) The most common organism is Hemolytic Staph Aureas. The cracked nipple is the usual initial lesion and method of entry for the organism causing mastitis. Mastitis manifests as a red, firm, tender mass in the breast. Axillary lymph nodes are swollen and client may feel an overall feeling of illness. Lowdermilk Chap 34 Pg. 834
The doctor diagnoses a shoulder dystocia, what is the preferred maneuvers for this obstetrical emergency? A) Forceps B) Vacuum extractor C) Cesarean section D) McRobert's Maneuver
D) Forceps and vacuums would be inappropriate because during a shoulder dystocia, the head has already been delivered and they would be of no use. There is no time for a cesarean section. The preferred method is to use the McRoberts maneuver where the womans legs are flexed apart, with her knees on her abdomen. Lowdermilk, Chapter 32, pp. 796 -797
A nurse is teaching a client who is at 12 weeks of gestation and has HIV. Which of the following statements should the nurse include in the teaching? A) "Breastfeed your newborn to provide passive immunity." B) "Abstain from sexual intercourse throughout the pregnancy." C) "You will be in isolation after delivery." D) "You should continue to take zidovudine throughout the pregnancy."
D) Rationale:The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.
A nurse is caring for a client whose last menstrual period began July 8. Using Nagele's rule, the nurse should identify the clients estimates date of birth as which of the following? A) October 1 B) April 1 C) October 15 D) April 15
D) Rationale:Using Nagele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days.
A pregnant client is being seen in the prenatal clinic. In documenting her OB History using Gravida- TPAL designation, how would the nurse document the following history? Son was born at 38 weeks, daughter was born at 32 weeks and they are alive and well. A) G3-T1-P1-A0-L1 B) G2-T1-P2-A1-L2 C) G3-T2-P0-A1-L2 D) G3-T1-P1-A0-L2
D) The Mother is pregnant now and has two other children so the Gravida is 3; had one term baby so term is one; had one pregnancy preterm so preterm is one; and 2 are living per her report.
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) Rationale:The nurse should provide counter pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain.
Multiple marker (MSAFP, unconjugated estriol, hCG and inhibin A) screens such as the triple or quad screen are used to screen for which of the following abnormalities? SATA a. Trisomy 21 (Down syndrome) b. Neural tube defects c. Preterm labor d. Gender e. Trisomy 18
a, b, e Triple or quad screening is done in the second trimester, ideally between 16-18 weeks gestation to screen for chromosomal abnormalities such as trisomy 18, trisomy 21 and neural tube defects.
A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vitamin K IM d. perform a detailed physical assessment
a. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. What following statements should the nurse make? a. blood pools in the vagina when you are lying in a bed b. the amount of blood flow will increase during the first few days after giving birth c. you might have retained placental fragments in your uterus d. you might have a damaged blood vessel
a. in the early postpartum period, lochia will pool in the vagina when the client is lying in bed & will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7
b. The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.
A nurse is administering a rubella immunization to a client who is 2 days postpartum. What statement indicates to the nurse the client needs further instruction? a. I cannot receive rubella immunization during pregnancy b. I can conceive anytime i want after 10 days c. I can continue to breastfeed d. I will still need to have my provider perform a rubella titer with my next pregnancy
b. a client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. What instructions should the nurse include in the teaching? a. use prepackaged commercial wipes to clean the circumcision site b. encourage nonnutritive sucking for pain relief c. remove the yellow exudate with each diaper change d. apply the diaper tightly over the circumcision area
b. allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management
A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclera c. resp rate 50 d. blood glucose 60
b. jaundice of the sclera If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain.
A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions? a. mag sulfate b. methylergonovine c. terbutaline d. nifedipine
b. methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. stand under hot shower with your breasts exposed b. place ice packs on your breasts c. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra
b. place ice packs on your breasts The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body produces milk.
A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the nurse take to promote development? a. discourage the use of pacifiers b. position the naked newborn on the parents bare chest c. provide frequent periods of visual and auditory stimulation d. rapidly advance oral feedings
b. position the naked newborn on the parents bare chest Positioning the naked newborn on the parent's bare chest can decrease stress in the parent & the newborn. The action can help maintain thermal stability, raise oxygen saturations, increase feeding strength, & promote breastfeeding
A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification? a. initiate bedrest with HOB elevated b. initiate high-fiber diet for client c. monitor clients weight weekly d. monitor client's I&O
c. The nurse should weigh the client daily to monitor for fluid overload.
A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milk b. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore
c. cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day
A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect? a. heel creases covering the bottom of the feet b. good flexion c. abundant lanugo d. dry, parchment-like skin
c. abundant lanugo Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.
A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rate b. blood pressure c. fundal consistency d. urinary output
c. fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterus b. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area
c. slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration.
Your healthy client is 24 weeks gestation and she asks when her next appointment should be scheduled. Which is the best response? A) "Schedule it for 1 week" B) "Schedule it for 2 weeks" C) "Schedule it for 3 weeks" D) "Schedule it for 4 weeks"
d. Antepartum appointments are scheduled every 4 weeks until 28 weeks gestation. Appointments are every 2 weeks from 28 to 36weeks. At 36 weeks, the appointments are every week until delivery.
A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl suppository d. assist the client to empty her bladder
d. When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.
A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway
d. walking can help stimulate peristalsis, which will promote expulsion of gas
A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include? a. discard unused refrigerated formula after 72 hrs b. prop the bottle with a blanket for the last feeding of the day c. dilute ready-to-feed formula if the newborn is gaining wt too quickly d. boil water for powdered formula for 1-2 min
d. boil water for powdered formula for 1-2 min the parents should run tap water for 2min and then boil it for 1-2min before mixing it with the formula to decrease the risk of contamination
A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. moro b. babinski c. rooting d. tonic neck
d. tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.
When the fetus dies in utero but is not expelled, it is classified as a: A) Inevitable abortion B) Threatened abortion C) Incomplete abortion D) Missed abortion
D)
Total blood volume increases approximately _____ in a pregnant woman to perfuse the placenta. A) 10% B) 20% C) 45% D) There is no blood volume increase during pregnancy
C)
A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? SATA (ATI MN p.57) A) Joint pain B) Malaise C) Rash D) Urinary frequency E) Tender lymph nodes
A) B) C) E)
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? (ATI MN p.47) A) Hyperemesis gravidarum B) Threatened abortion C) Hydatidiform mole D) Preterm labor
C)
A nurse is assessing a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as an indicator of fetal compromise? A) Client report of quickening B) Fundal height of 22 cm C) Fetal heart rate of 110/min D) Absence of protein in the client's urine
C)
Changes in the cervical and vaginal color are referred to as: A) Hegar's Sign B) Granlev's Sign C) Braxton-Hicks Sign D) Chadwick's sign
D)
A nurse is assessing a 12 hr old newborn and notes a resp rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion
a. the nurse should continue routine monitoring because the newborn's assessment findings indicate he is adapting to extrauterine life
A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse expect? a. symmetric rib cage b. lanugo abundant on the back c. dry, wrinkled skin d. vernix over the entire body
a. symmetric rib cage a newborn who is born at 39 weeks of gestation is full-term & should have a symmetric rib cage
A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3-4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe
a. this will resolve within 3-6 wks without treatment This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum, that will resolve within 2 to 6 weeks.
A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm
c. The newborn should always sleep on his back to prevent sudden infant death syndrome.
A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include? (ATI MN p.25) A) Eat crackers or plain toast before getting out of bed. B) Awaken during the night to eat a snack. C) Skip breakfast and eat lunch after nausea has subsided. D) Eat a large evening meal.
A)
A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having more doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? A) "Ambivalent feelings are quite common for women early in pregnancy." B) "Perhaps you should see a counselor to discuss these feelings further." C) "Have you spoken to your mother about these feelings?" D) "Don't worry. You will be fine once the baby is born."
A)
A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider? A) Respiratory depression B) Facial flushing C) Nausea D) Drowsiness
A)
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following actions should the nurse take? (ATI MN p.131) A) Come back later when the client is more cooperative. B) Give the client time to express feelings. C) Tell the client they need to be quiet so the assessment can be completed. D) Redirect the client's focus so that they will become quiet.
B)
A client who is at 8 weeks of gestation tells the nurse, "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make? (ATI MN p.25) A) "I will inform the provider that you are having these feelings." B) "It is normal to have these feelings during the first few months of pregnancy." C) "You should be happy that you are going to bring new life into the world." D) "I am going to make an appointment with the counselor for you to discuss these thoughts."
B)
A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? A) Fetal lung maturity B) Location of the placenta C) Viability of the fetus D) The biparietal diameter
B)
A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? (ATI MN p.64) A) HgB 12.2 g/dL B) Urine ketones present C) Alanine aminotransferase 20 IU/L D) Blood glucose 114 mg/dL
B)
A sign of true labor is: A) Contractions beginning to be felt by the client B) Progressive cervical change C) Contractions that are relieved by walking D) Loss of the cervical plug
B)
A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100 to 110 seconds and that the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take? A) Decrease the infusion rate of the maintenance IV fluid B) Administer oxygen via nonrebreather mask C) Decrease the dose of oxytocin by half D) Administer terbutaline 0.25 mg subcutaneously
C) Rationale:The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.
A biophysical profile (BPP) may be ordered to determine fetal well-being. Which of the following indicates a complete BPP with an adequate score? a. Fetal breathing movement (2), fetal tone (2), fetal weight (2), AFI (2), fetal movement (2) b. AFI (1), Fetal breathing movement (1), fetal tone (2), fetal movement (2), NST (2) c. Fetal breathing movement (2), fetal tone (2), NST (0), AFI (2), fetal movement (2) d. AFI (0), Fetal breathing movement (2), fetal tone (2), fetal movement (2), NST (2)
C) Biophysical Profile measures 5 components (AFI, Fetal breathing movement, fetal tone, fetal movement, NST) for fetal well-being. Each component gets a 0 for an abnormal finding or 2 for a normal finding. A total score of 8-10 with a normal AFI indicates fetal well-being.
Presumptive signs of pregnancy are: A) All objective signs of pregnancy. B) Those perceived by the healthcare provider. C) Subjective physiological changes felt by the woman. D) Primarily musculoskeletal symptoms felt by the woman.
C) Presumptive signs are the subjective findings stated by the client but cannot be heard, felt, or seen by the examiner. Probable are the objective findings that can be visualized, palpated, seen or heard by the examiner. Positive signs cannot be explained by anything other than pregnancy.
A client calls a providers office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? (ATI MN p.79) A) Braxton hicks contractions B) Rupture of the membranes C) Fetal descent D) True contractions
D)
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? (ATI MN p.131) A) Hand the parent the newborn, and suggest they change the diaper. B) Ask the parent why they are so anxious and nervous. C) Tell the parent that they will grow accustomed to the newborn. D) Provide education about infant care when the parent is present.
D)
A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? (ATI MN p.29) A) Iron deficiency anemia B) Poor bone formation C) Macrosomic fetus D) Neural tube defects
D)
A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A) Left lower B) Right lower C) Left upper D) Right upper
D)
A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? (ATI MN p.70) A) Use a condom with sexual intercourse B) Avoid bubble bath solution when taking a tub bath C) Wipe from the back to front when performing perineal hygiene D) Keep a daily record of fetal kick counts
D)
A nurse is reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? (ATI MN p.29) A) "I am glad I can have my morning coffee." B) "I should take folic acid to increase my milk supply." C) "I will continue adding 330 calories per day to my diet." D) "I will continue my calcium supplements because I don't like milk."
D)
The black tarry substance expelled from the rectum of the newborn is called: A) Bilirubin B) Vernix caseosa C) Lanugo D) Meconium
D)
A client presents to the hospital at 34 weeks gestation with complaints of moderate vaginal bleeding. Which of the following nursing interventions should the nurse perform first? A) Vaginal exam B) Start an IV C) Call the provider D) Apply electronic fetal monitor
D) The electronic fetal monitor will let the nurse know how the fetus is doing with the vaginal bleeding. The nurse should never do a vaginal exam with vaginal bleeding until the cause has been identified. If the bleeding is from a placenta previa, the nurse could puncture the placenta when doing a vaginal exam. The nurse should do a quick assessment of the client and fetus before notifying the provider to know what to tell the provider. An IV might need to be started but not first.
The nurse caring for a client with HELLP syndrome would anticipate which of the following lab findings? SATA a. Thrombocytopenia b. Increased ALT c. Increased hemoglobin d. Increased WBC e. Increased potassium
a, b HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. You would see thrombocytompenia (low platelets), Increased ALT/AST (elevated liver enzymes), and decreased hemoglobin (hemolysis).
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings
b. Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV. What meds should the nurse have available at bedside? a. naloxone b. protamine sulfate c. calcium gluconate d. atropine
c. calcium gluconate The nurse should have calcium gluconate available to give to a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes.