OB ATI quiz 2
A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? A. Within 2 days B. In 3-5 days C. In 6-8 days D. In about 10 days
B
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? A. Place the newborn under a radiant warmer B. Obtain blood glucose by heel stick C. Monitor the newborn's blood pressure D. Initiate phototherapy
B
A nurse on a L/D unit is admitting a client who reports painful contactions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 minutes. The nurse obtains the following vital signs: Mom's HR 128/mim, mom's BP 92/54 mm Hg; FHR 130/min. Which is the priority: A. Notify the provider B. Position the client with one hip elevated C. Ask the client if she needs pain medications D. Have the client void
B
a nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice A. Begin phototherapy B. Initiate early feeding C. Suction excess mucus with a bulb syringe D. Prepare for an exchange blood transfusion
B
A nurse is preparing to administer 1 mg vitamin K to a NB. The medication is availale in 1mg/0.5 ml. How much should the nurse administer. (Round to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero)
0.5 ml
A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus (PDA). Which of the following findings should the nurse expect? A. Cyanosis w/ crying B. Systolic murmur C. Weak pulses D. Chronic hypoxemia
B
A nurse is assisting a client with breastfeeding. the nurse explains that which of the following reflexes will promote the newborn to latch? A. Babinski B. Rooting C. Moro D. Stepping
B
A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis? A. Swelling in the breast B. Cracked and bleeding nipple C. Red and painful area in one breast D. A white patch on a nipple
B
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?
"You should place your nipple and some of the areola into her mouth"
A nurse is caring for a newborn and calculating the Apgar score. At 1 minute after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score.
6
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? A. Respiratory distress B. Hypothermia C. Accidental lacerations D. Acrocyanosis
A
A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? A. Expressions of excitement B. Lack of appetite C. Focus on the family unit and its members D. Eagerness to learn newborn care skills.
A
A nurse is caring for a client who has just delivered a newborn. Following the delivery, which nursing action schould be done first to care for the newborn? A. Clear respiratory tract B. Dry the infant and cover the head C. Stimulate the infant to cry D. Cut the umilical cord
A
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? A. Uteroplacental insufficiency B. Maternal bradycardia C. Unbilical cord compression D. Fetal head compression
A
A nurse is teaching a client who is postpartum and has a new Rx of an injection of Rh0 (D) immunoglobulin. Which of the following should be included in the teaching? A. It prevents the formation of Rh antibodies in mothers who are Rh negative B. It destroys Rh antibodies in mothers who are Rh negative C. It destroys Rh antibodies in newborns who are Rh positive D. It prevents the formation of Rh antibodies in newborns who are Rh positive
A
A nurse on a postpartum unit is caring for a group of clients with assistive personnel(AP).Which of the following tasks should the nurse plan to delegate to the AP? A. Provide a stizs bath to a client who has a fourth-degree laceration and is 2 days postpartum. B. Observe an area of redness on the breast of a client who is 1 day postpartum C. Monitor vital signs during admission of a client who has gestational HTN D. Change the perineal pad of a client who just transferred from labor and delivery.
A
A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility B. Physiologic jaundice C. Absence of vitamin K D. Maternal cocaine use
A Rational : most common form of pathologic jaundice; appears within the 1st 24 hrs of life. Physiologic jaundice appears after 24 hrs.
A nurse is preparing to assess a newborn who is post mature. Which of the following findings should the nurse expect? (Select all that apply.) A. Cracked, peeling skin; B. positive moro reflex C. Short, soft fingernails D. Abundant lanugo E. Varnix in the folds and creases
A, B Also, fingernails are long and hard. Vernix in the folds-- in mature, term newborns. Abundant lanugo-- in preterm <37 weeks newborns
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? A. Apply breast milk to the nipples before each feeding B. Place breast pads inside the nursing bra C. Massage the breasts and nipples prior to feeding. D. Start breastfeeding with the nipple that is less sore E. Change the infant's position on the nipples
A, D, E
A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include? A. Wash the cord daily with mild soap and water. B. Cover the cord with the diaper C. Apply petroleum jelly to the cord stump D. Give the newborn a sponge bath until the cord stump falls off.
D
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was deaf and asks how to tell if her newborn hears well. Ehich of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks at you when you speak. That's a good sign." C. "We so routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "the best way to determine if your baby can hear is to clap your hands loudly and see if she startles."
C
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? A. "Preterm newborns have a smaller body surface area than normal newborns." B. " The added brown fat layer in a preterm newborn reduces his ability to generate heat." C. "Preterm newborns lack adequate temperature control mechanisms." D. "The heat in the incubator rapidly dries the sweat of preterm newborns."
C
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placcing the newborn on a warm surface B. Preventing air drafts C. Drying the newborn's skin thorougly D. Maintaining ambient RT at 24 degree C (75 F)
C
A nurse is caring for a newborn delivered by vaginal birth with vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the sweling crosses the suture line, which of the following is an appropriate response by the nurse? A. "This is erythema toxicum, which is a transient condition." B. "This is a cephalhematoma, which can occur spontaneously." C. "A caput succedaneum occurs due to compression of blood vessels." D. "Mongolian spots can be found on the skin of many newborns."
C It presents at birth (area of edema on newborns occiput where the cup of vaccum was applied) and will disappear within 3-4 days.
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A. NB who is 24 hr post delivery and not voided B. NB who is 18 hr post delivery and has acrocyanosis C. NB who is 24 hr post delivery and has not passed meconium D. NB 12 hr post delivery temp 37.5 C (99.5 F)
D
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?
The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.