ATI 2

A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client? A. "Notify your baby's pediatrician if he urinates less than six times a day." B. "Swaddle your baby tightly with his legs extended before laying him down to sleep." C. "Place triple antibiotic ointment on your baby's umbilical cord twice per day." D. "Retract the foreskin to clean your baby's penis during each bath."

A. "Notify your baby's pediatrician if he urinates less than six times a day."

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse? A. "The discharge is common during the first 24 to 72 hours following a circumcision." B. "I will need to obtain a sample of the discharge for laboratory testing." C. "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours." D. "Apply povidone-iodine solution twice daily to the circumcision site."

A. "The discharge is common during the first 24 to 72 hours following a circumcision."

A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion? A. Administer oxygen to the client via a face mask at 10 L/min. B. Place the client in a Trendelenburg position. C. Assist the client to void. D. Give calcium gluconate to the client.

A. Administer oxygen to the client via a face mask at 10 L/min.

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? A. Cleanse the site with povidone-iodine. B. Administer broad-spectrum antibiotics. C. Prepare for surgical closure after 72 hours. D. Monitor the rectal temperature every 4 hours. E. Monitor the rectal temperature every 4 hours.

A. Cleanse the site with povidone-iodine.

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? A. The newborn's pulse oximetry is 91%. B. The newborn's respiratory rate is irregular. C. The newborn is beginning to cough. D. The newborn's respiratory rate is 32/min.

A. The newborn's pulse oximetry is 91%.

A nurse is caring for a client who is in active labor and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client's blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse suspect? A. Uterine rupture. B. Amniotic fluid embolism. C. Placenta previa. D. Umbilical cord prolapse.

A. Uterine rupture.

A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include? A. "Your bleeding will remain bright red for the next 6 to 8 weeks." B. "You can expect your breasts to be firm and tender 3 to 5 days after delivery." C. "You don't need to use birth control if you are exclusively breastfeeding." D. "You should begin performing Kegel exercises 6 to 7 weeks after delivery."

B. "You can expect your breasts to be firm and tender 3 to 5 days after delivery."

A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has preeclampsia and a creatinine level of 1.1 mg/dL. B. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L. C. A client who has diabetes mellitus and an HbA1C of 5.8%. D. A client who has placenta previa and a hematocrit of 35%.

B. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L.

A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? A. A client who is at 12 weeks of gestation and is experiencing nausea and vomiting. B. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache. C. A client who is at 38 weeks of gestation and is experiencing painful urination. D. A client who is at 39 weeks of gestation and is experiencing cramping and spotting.

B. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache.

A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes mellitus. Which of the following findings should the nurse report to the provider? A. Platelets 170,000/mm³. B. HbA1c 6%. C. BUN 25 mg/dL. D. Hct 34%.

B. HbA1c 6%.

A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications? A. Terbutaline. B. Methylergonovine. C. Hydralazine. D. Betamethasone.

B. Methylergonovine.

A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? A. Hypertension. B. Urine output 20 mL/hr. C. Hyperglycemia. D. Respiratory rate 16/min

B. Urine output 20 mL/hr.

A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Ultrasound is used to observe for placental maturity in the first trimester." B. "Ultrasound is used to detect intrauterine growth restriction in the first trimester." C. "Ultrasound is used to determine gestational age in the first trimester." D. "Ultrasound is used to perform a biophysical profile in the first trimester."

C. "Ultrasound is used to determine gestational age in the first trimester."

A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for Group B Streptococcus β-hemolytic. Which of the following medications should the nurse plan to administer to the client? A. Cefotetan. B. Fluconazole. C. Ampicillin. D. Doxycycline.

C. Ampicillin.

A nurse is admitting a client who is in active labor and has had two prior cesarean births. The nurse should identify that the client is at an increased risk for which of the following complications? A. Precipitous labor. B. Abruptio placentae. C. Uterine rupture. D. Failure to progress.

C. Uterine rupture.

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Give the newborn 1 oz of glucose water every 4 hours. B. Apply a thin layer of lotion to the newborn's skin every 8 hours. C. Ensure the newborn's eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy.

C. Ensure the newborn's eyes are closed beneath the shield.

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? A. Maintain airborne precautions in the nursery. B. Place the newborn's foot on a sterile field during a heelstick. C. Place newborn bassinets at least 3 feet apart. D. Allow parents to enter the nursery if they are wearing a mask.

C. Place newborn bassinets at least 3 feet apart.

A charge nurse is teaching a newly licensed nurse about Rho(D) immune globulin administration. Which of the following should the charge nurse include as an indication for the administration of Rho(D) immune globulin? A. Hyperemesis gravidarum. B. Rh-positive blood test results. C. Prescription for an amniocentesis. D. Anemia.

C. Prescription for an amniocentesis.

A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse? A. One acceleration of the FHR within a 20-min period. B. Uterine contractions lasting 20 to 30 seconds each. C. Three uterine contractions within a 20-min period. D. An FHR that peaks 20 beats above the baseline.

C. Three uterine contractions within a 20-min period.

A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? A. Deep tendon reflexes of 2+. B. Blood glucose 110 mg/dL. C. Urine protein of 3+. D. Hemoglobin 13 g/dL.

C. Urine protein of 3+.

A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect? A. Temperature 37.4°C (99.3°F). B. Scant lochia. C. Uterine tenderness. D. WBC count 9,000/mm³.

C. Uterine tenderness.

A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching? A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth." B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8." C. "The nurse should wait for the first Apgar score before initiating resuscitation efforts." D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score."

D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score."

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching? A. "This test will determine the amount of amniotic fluid around the fetus." B. "This test determines if your baby is at risk for developing hypoglycemia after birth." C. "This test studies blood flow in the fetus and placenta using ultrasound waves." D. "This test will detect the presence of Rh-positive antibodies in your blood."

D. "This test will detect the presence of Rh-positive antibodies in your blood."

A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Keep the newborn supine throughout treatment. B. Dress the newborn in lightweight clothing. C. Measure the newborn's temperature every 8 hours. D. Avoid using lotion or ointment on the newborn's skin.

D. Avoid using lotion or ointment on the newborn's skin.

A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 55/min. B. Blood pressure 80/50 mm Hg. C. Temperature 36.5°C (97.7°F). D. Heart rate 72/min.

D. Heart rate 72/min.

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? A. Increased respiratory rate. B. Increased fetal movement. C. Increased urinary output. D. Increased muscle weakness.

D. Increased muscle weakness.

A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 minutes. Which of the following actions should the nurse take? A. Place the client in the Trendelenburg position. B. Conduct a vaginal exam. C. Collect a specimen for an indirect Coombs test. D. Perform vibroacoustic stimulation.

D. Perform vibroacoustic stimulation.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Swaddle the newborn with his legs extended. B. Maintain eye contact with the newborn during feedings. C. Schedule larger volume feedings at less frequent intervals. D. Plan care to minimize handling of the newborn.

D. Plan care to minimize handling of the newborn.

A nurse is developing an educational program about hemolytic disease in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease? A. The mother and the father are both Rh negative. B. The mother and the father are both Rh positive. C. The mother is Rh positive and the father is Rh negative. D. The mother is Rh negative and the father is Rh positive.

D. The mother is Rh negative and the father is Rh positive.