ATI - Maternal Neonatal

d

A 2-week-old neonate is admitted to the hospital with a diagnosis of possible sepsis. The neonate weighs 3.2 kg. The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? a) Ampicillin 200 mg/kg intravenously every 6 hours b) Acetaminophen 10 mg/kg per rectum, every 4 to 6 hours prn pain c) Mom may breast-feed ad lib. d) Draw blood cultures × 3 in AM.

a c

A nurse is caring for a client who is in the third stage of labor. Which characteristic behaviors does the nurse anticipate at this stage? Select all that apply. a) The client states she has discomfort from uterine contractions. b) The client is exhausted from continued pushing. c) The client is focused on the neonate's condition. d) The client is apprehensive about the process. e) The client is excited about the process. f) The client is feeling embarrassed as she has an urge to defecate.

b d e

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply. a) The neonate turns toward the nurse's finger when touching the cheek. b) The neonate displays weak, ineffective sucking. c) The neonate does stepping movements when held upright with the sole of the foot touching a surface. d) The neonate does not respond when the nurse claps hands. e) The neonate's toes do not curl downward when the soles of the feet are touched. f) The neonate grasps the nurse's finger when put in the palm of the neonate's hand.

a c d

A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. a) Talks to and coos at her son b) Requests that the nurse take the baby to the nursery for feedings c) Cuddles her son close to her d) Counts the fingers and toes of her son e) Takes a nap when the baby is also sleeping f) Does not make eye contact with her son

a b c d

The nurse is admitting a client with suspected diagnosis of abruptio placentae. When assessing client symptoms, which symptoms require health care provider notification of this medical emergency? Select all that apply. a) Increased blood pressure b) Rapid uterine contractions c) A rigid abdomen d) Overt vaginal bleeding e) Gastrointestinal upset f) White creamy vaginal discharge

c

The nurse is caring for a newborn with a heart defect that involves mixing blood from the pulmonary and systemic circulation. Which illustration shows a congenital heart disorder with mixed blood flow? a) 4 b) 3 c) 2 d) 1

a

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes below, which rationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy? a) To prevent compression of the vena cava b) To facilitate digestion c) To prevent development of fetal anomalies d) To facilitate bladder emptying

d

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart, into which of the following positions would the nurse assist the client? a) Supine b) Prone c) Right lateral d) Left lateral

a b c

A client who is 29 weeks pregnant comes to the labor and birth unit. She states that she is having contractions every 8 minutes. The client is also 3 cm dilated. Which of the following can the nurse expect to administer? Select all that apply. a) Betamethasone b) A β-2 agonist c) Intravenous fluids d) Folic acid e) Nalbuphine f) Rho(D) immune globulin (RhoGAM)

2 5 3 4 1

A neonate has been placed on cardiac and apnea monitoring in the neonatal nursery. The nurse notes that the apnea alarm repeatedly triggers. Place the following actions in the order in which they would be completed by the nurse. All options must be used. 1. Document the assessment findings, interventions, and neonate's response. 2. Perform a focused assessment on the neonate. 3. Silence the alarm to decrease environmental stimuli. 4. Check all connects on apnea monitor. 5. Count the respiratory rate for 60 seconds.

a

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown below). Which term best identifies the discharge? a) Lochia rubra b) Lochia serosa c) Lochia d) Lochia alba

d e

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip (DDH)? Select all that apply. a) Negative Ortolani test b) Limitation in adduction of the affected leg c) Lengthening of the affected leg d) Positive Barlow test e) Asymmetrical leg skin folds

a c

A postpartum client is experiencing thoughts and behaviors common to the taking-hold phase. Which items are characteristic of this phase? Select all that apply. a) Holds new child and breast-feeds without prompting b) Prefers having the nurse care for her c) Expresses a strong interest in taking care of her child d) Gives up fanaticized image of her child and accepts the real one e) Rests to regain physical strength and calm her swirling thoughts

a c

During physical assessment of a client who gave birth 3 hours ago, a nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which nursing actions would be appropriate? Select all that apply. a) Assess the client's vital signs. b) Place the client in high Fowler's position. c) Palpate the client's fundus. d) Place client on bedrest. e) Begin an intravenous infusion of lactated Ringer's solution.

d

The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse below, which action is most appropriate at this time? a) Straight catheterize the client for half of her urine volume. b) Call the client's primary health care provider for direction. c) Raise the head of the bed. d) Ask the client to empty her bladder. e) Notify the charge nurse of the assessment findings.

c d

The nurse is assigned to a client who experiences a syncopal episode on her first ambulation after childbirth. Which nursing actions will the nurse delegate to the licensed practical/vocational nurse (LPN/VN)? Select all that apply. a) Monitor hemoglobin and hematocrit level. b) Assess pain level on a 0 to 10 pain scale. c) Obtain a cool compress for the head. d) Assist the nurse with ambulating the client back to bed. e) Assist with ambulation on the next trip to the bathroom. f) Obtain orthostatic blood pressures.

85

The nurse is caring for a neonate who has a suspected neonatal sepsis. The health care provider's order is for ampicillin 100 mg/kg/day to be given in four divided doses. The client weighs 7 lb, 8 oz (3.4 kg). How many milligrams would the nurse give with each dose? Record your answer using a whole number. ___________mg/dose

a b c d f

The nurse is caring for a newborn boy of Hispanic heritage. According to the beliefs of this heritage, which would the nurse expect? Select all that apply. a) The neonate must be bundled at all times. b) The neonate will wear a red or pink bracelet. c) Breast-feeding is common and strongly encouraged. d) The maternal elders offer advice to the new mother. e) The neonate will be circumcised by a medicine man. f) The umbilical cord will be kept covered by snug clothing.

a

The nurse is documenting assessment findings of the newborn. When assessing the neonate's head, the following is noted. Upon further exam, swelling is limited to below the scalp on the left side of the head. How does the nurse document this finding most accurately on the admission assessment to the nursery? a) A cephalhematoma contained on the left side. b) Bleeding on the brain causing a lump. c) Swelling on the dorsal area of the skull. d) Caput succedaneum on the left side of the head.

a

The nurse is performing Leopold's maneuvers to determine fetal presentation and position. Which illustration shows the third maneuver? a) 4 b) 2 c) 3 d) 1

3 2 4 1 5

The nurse is performing an assessment of a client progressing through labor. Place the following findings in the order in which they occur. All options must be used. 1. 100% cervical effacement 2. Mild contractions lasting 20 to 40 seconds 3. Strong Braxton Hicks contractions 4. Cervical dilation of 7 cm 5. Uncontrollable urge to push

5 2 3 4 1 6

The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. Order the sequence of events for performing this procedure. All options must be used. 1. Rotate the upper hand to massage the uterus until firm. 2. Place the client in supine position. 3. Place one hand on the abdomen just above the symphysis pubis. 4. Place one hand around the top of the fundus. 5. Ask the client to void. 6. Gently press the fundus between the hands using slight downward pressure.

a

The obstetric nurse is performing a nonstress test on a 30-week primigravida client sent from a health care provider's office. The client reports a decrease in fetal movement over the past 24 hours. The nurse documents the following nursing note. Which nursing statement is appropriate at this time? a) "I will check with the health care provider to see if further tests are needed." b) "I bet you are excited about the baby." c) "Have you done anything different today?" d) "Let's have you change your position and lie on your left side."

a b d f

A client at 32 weeks of gestation has mild preeclampsia. She is discharged home with instructions to remain in bed rest. She would also be instructed to call her health care provider if she experiences which of the following symptoms? Select all that apply. a) Epigastric pain b) Severe nausea and vomiting c) Increased urine output d) Blurred vision e) Difficulty sleeping f) Headache

63

A client is at risk for seizures because of pregnancy-induced hypertension. The health care provider orders 4-g magnesium sulfate in 250-ml D5W to be infused at 1 g/hour following a loading dose. What is the flow rate in milliliters per hour? Round your answer to the nearest whole number. _________ ml/hour

a b f

A client is being admitted to the labor and birth unit. Her GTPAL classification is 5-2-1-1-2. When providing shift handoff, which information would the nurse include? Select all that apply. a) The client has had four previous pregnancies. b) The client has had two full-term children, one premature child, and one abortion. c) The client has had one full-term child, one abortion, and one premature child. d) The client has three living children following five pregnancies. e) The client has had five previous pregnancies. f) The client has two living children and is pregnant again.

b c

A graduate nurse is explaining to the nurse mentor how to assess newborn jaundice and the effects of phototherapy in a dark-skinned neonate. Which statement made by the graduate nurse would need clarification? Select all that apply. a) "It is best to observe for jaundice in the conjunctival sac or oral mucosa." b) "The neonate will be irritable from the elevated bilirubin in the system." c) "I will carefully record the neonate's intake as limiting fluids is helpful." d) "Phototherapy treatment can increase the risk of dehydration." e) "I will monitor the unconjugated bilirubin carefully as it is the dangerous one."

a c d e f

A mother with a history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below would lead to this nursing judgment? Select all that apply. a) Confusion b) Chills, fever c) Sudden dyspnea d) Chest pain e) Cough f) Diaphoresis

20

A postpartum client has been ordered 500 mg of ampicillin oral suspension. The label reads ampicillin 125 mg/5 ml. How many milliliters would the client receive? Record your answer using a whole number. _________ ml

c e f

A woman at 15 weeks of gestation comes to the clinic for an amniocentesis. If an abnormal result is found, which characteristics or problems could be identified? Select all that apply. a) Fetal lung maturity b) Polyhydramnios c) Chromosomal defects d) Gestational diabetes e) Neural tube defects f) Sex of the fetus

d

A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period? a) Holding out b) Letting go c) Taking hold d) Taking in

c d e

A nurse is caring for a postterm client at 41 weeks of gestation who is about to undergo a biophysical profile (BPP) to evaluate her fetus's well-being. The client asks, "What will be able to be determined from this test?" The nurse is correct to answer which? Select all that apply. a) Crown-rump length b) Femur length c) Amniotic fluid volume d) Fetal breathing e) Fetal tone f) Biparietal diameter

0.25

A nurse is administering vitamin K to a neonate following birth. The medication comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters would the nurse administer? Record your answer using two decimal places. _________ml

a d e

A client at 30 weeks gestation experiences a rupture of membranes with mild contractions eight (8) minutes apart. Which nursing interventions are included on the plan of care to improve newborn outcomes? Select all that apply. a) Arrange a neonatologist to be available for the birth b) Ensure the mother remains nothing by mouth (NPO) throughout the labor c) Position the mother in a supine position with the feet elevated. d) Maintain the client on the fetal monitor throughout the labor process e) Administer a dose of Betamethasone per healthcare providers order f) Begin a oxytocin (Pitocin) drip once the mother reaches 3 cm dilated

d

A home care lactation nurse has asked a client to keep a record of her intake, including calories, and output for 1 day. After reviewing the flow sheet that the client used to document the results, the nurse would make which assessments? a) The client consumed an adequate amount of fluids but not enough calories for breast-feeding. b) The client consumed an adequate amount of calories but not enough fluids for breast-feeding. c) The client consumed an adequate amount of calories and fluids for breast-feeding. d) The client consumed an inadequate amount of fluids and calories for breast-feeding.

b

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note below, which postpartum complication has the client developed? a) Uterine rupture b) Postpartum hemorrhage c) Pylonephritis d) Urinary tract infection e) Puerperal infection

3 4 2 1

A nurse is preparing to teach a client about fetal growth and development during the first 3 months of pregnancy. The nurse is assembling teaching aids by milestones. In ascending order (month 1, month 2, month 3, and months 4 to 9), how would the nurse arrange the aids? 1. Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb. 2. Teeth and bones begin to appear, the kidneys start to function, and, at the end of the month, gender is distinguishable. 3. The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. 4. The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present.

b c e f

A nurse is caring for a client who is 32 weeks pregnant and being monitored in the antepartum unit for pregnancy-induced hypertension. The client suddenly reports continuous abdominal pain and vaginal bleeding. Which nursing interventions are priorities? Select all that apply. a) Reassure the client that she will be able to continue the pregnancy. b) Evaluate maternal vital signs. c) Monitor intake and output. d) Prepare for vaginal birth. e) Monitor the amount of vaginal bleeding. f) Auscultate fetal heart tones.

b c d

A nurse is caring for a client who is anxious to know her baby's due date. The nurse instructs the client on how to determine the baby's due date according to Nägele's rule. The client is correct to state which of the following when discussing the use of the rule? Select all that apply. a) "I will calculate 9 months from my last menstrual period." b) "Nägele's rule provides a good approximation of the due date." c) "Nägele's rule may be used in conjunction with other assessment findings." d) "I will add 7 days to the first day of my last menstrual period and count back 3 months." e) d

a b c d

A nurse is caring for a client with history of a warm, reddened, painful area in the breast diagnosed as mastitis as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding throughout treatment. Which instructions would the nurse include to prevent a recurrence of this condition? Select all that apply. a) Release the baby's grasp on the nipple before removing the baby from the breast. b) Change the breast pads frequently. c) Wash hands before handling the breast and breast-feeding. d) Expose the nipples to air for part of each day. e) Wash the nipples with soap and water. f) Make sure that the baby grasps the nipple only.

a d e f

A nurse is caring for a neonate born addicted to opiates in the special care nursery. The neonate is exhibiting signs of withdrawal. When planning care, which nursing interventions would the nurse expect to be included? Select all that apply. a) Administer morphine. b) Encourage parental handling. c) Increase environmental stimuli. d) Swaddle and/or provide a pacifier. e) Maintain intravenous fluids. f) Feed every 1 to 2 hours.

a d

A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which statements accurately characterize this disorder? Select all that apply. a) Symptoms include delusions and hallucinations. b) Suicide and infanticide are uncommon in this disorder. c) Symptoms appear at the 6-month screening. d) The disorder rarely occurs without a psychiatric history. e) The disorder is common in postpartum women.

b e f

A nurse is evaluating a client who is 34 weeks pregnant for preterm rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply. a) Cervical dilation of 6 cm b) Presence of amniotic fluid in the vagina c) Contractions occurring every 5 minutes d) Acidic pH of fluid when tested with nitrazine paper e) Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry f) Alkaline pH of fluid when tested with nitrazine paper

b d e

A nurse is evaluating the return demonstration of cord care by the mother of a neonate. Which actions would the nurse encourage the mother to perform? Select all that apply. a) Cleaning the length of the cord with alcohol several times daily b) Sponge bathing the infant until the cord falls off c) Tugging gently on the cord as it begins to dry d) Placing the diaper below the cord e) Washing the cord with mild soap and water f) Applying antibiotic ointment to the cord twice daily

4 1 2 3 5 6

A nurse is providing care to a neonate. Place the following steps in the order that the nurse would implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used. 1. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. 2. Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb. 3. Instill the ointment in the lower conjunctival sac. 4. Wash hands and put on gloves. 5. Close and manipulate the eyelids to spread the medication over the eye. 6. Repeat the procedure for the other eye.

c

A primigravida client arrives at the labor and birth unit at 39 weeks' gestation. After completing the initial assessment, the nurse documents the following: Which nursing action is anticipated per health care provider? a) Admit the client to the labor and birth unit and prepare for placement of an epidural catheter. b) Instruct the client to rest and turn on the left side. c) Provide instructions to remain within 10 minutes of the birthing center and to ambulate d) Prepare the client for a cesarean section

c e f

A registered nurse is delegating the monitoring of a client who is receiving oxytocin to induce labor to a new graduate nurse. When discussing adverse side effects of oxytocin, which conditions would the graduate nurse notify the registered nurse of immediately? Select all that apply. a) Jaundice in the sclera b) A heart rate of 60 beats/minute c) Palpable uterine tetany d) Lab work suggesting dehydration e) A blood pressure of 170/92 mm Hg f) Fluid overload with crackles in the lung fields

a b

The nurse is caring for a client in labor. Which assessment findings would prompt the nurse to notify the health care provider? Select all that apply. a) The client's membranes rupture, and the amniotic fluid is green. b) Late decelerations are noted on the external fetal monitor strip. c) The client is moaning in pain during contractions. d) The client is anxious and requests that someone help her. e) The fetal heart rate baseline is between 140 and 150 beats/minute. f) Blood-tinged mucus is noted upon internal examination.

a b c e

The nurse is caring for a family that is grieving the loss of their newborn. Which tokens of remembrance would be appropriate to provide? Select all that apply. a) A lock of hair b) A picture of the newborn c) The footprints d) A certificate of death e) An invitation to an annual remembrance service

b c d

The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which three neonates are the best client care assignment for the pediatric nurse? Select all that apply. a) A 1-day-old with a cleft palate and cleft lip b) A recent admission with Apgar score of 8 and 10 c) A 1-day-old with caput succedaneum d) A 4-hour-old with a bluish appearance to the hands and feet e) An 18-hour, postterm, breast-fed neonate with jaundice f) A 2-day-old who has not passed a meconium stool

b

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. Which nursing intervention would the nurse implement? a) Increase the intravenous fluid rate to boost intravascular volume. b) Reassure the client and continue to monitor the fetal heart rate. c) Place client is Fowler's position. d) Administer supplemental oxygen. e) Require the client to lie on her left side.

1 2 3 4

A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used. 1. Increment 2. Acme 3. Decrement 4. Relaxation

a

At 5 minutes of age, a neonate is pink with acrocyanosis; has flexed knees, clenched fists, a whimpering cry, and a heart rate of 128 beats/minute; and withdraws the foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate? a) 8 b) 7 c) 10 d) 5

c

During a prenatal visit, a health care provider decides to admit a client to the hospital. Based on the nurse's admission note below, which complication of pregnancy would the health care provider suspect? a) Placenta previa b) Iron deficiency anemia c) Hyperemesis gravidarum d) Pregnancy-induced hypertension

1 3 4 2 5

During her first prenatal visit, a client asks a nurse what physiological changes she can expect during pregnancy. The nurse begins the discussion with the presumptive changes of pregnancy. Put the following presumptive changes in ascending chronological order according to when they occur. 1. Breast changes 2. Quickening 3. Frequent urination 4. Uterine enlargement in which the uterus can be palpated over the symphysis pubis 5. Appearance of linea nigra, melasma, and striae gravidarum

b c f

Five days postpartum following an uneventful vaginal birth, a client phones the obstetrician's office stating various symptoms and requesting an appointment. As the nurse is documenting symptoms, which indicate a potential puerperal infection? Select all that apply. a) Serosanguineous drainage on the perineal pad b) Reddened area increasing around episiotomy c) Frequent abdominal pain requiring medication d) Ecchymosis in the perineal area e) Slight edema to perineum f) Temperature of 100.8°F (38.2°C)

a b e f

Following the admission assessment of a neonate born at 42 weeks of gestation, the nurse documents which findings as normal? Select all that apply. a) Absence of vernix caseosa b) Cyanosis of the hands and feet c) Large amounts of frothy oral secretions d) Absence of sole creases e) A three-vessel umbilical cord f) Peeling skin on the feet

b

The nurse is assisting with the birth of a fetus in a frank breech presentation. Which graphic illustrates that position? a) 4 b) 3 c) 1 d) 2

b c d e

The nurse is giving prenatal instructions to a 32-year-old primigravida. Which nutritional instructions would the nurse review? Select all that apply. a) Vitamin intake would not increase from prepregnancy requirements. b) Protein intake would be increased to more than 30 g/day. c) Intake of all minerals, especially iron, would be increased. d) Caloric intake would be increased by 300 cal/day. e) Folic acid intake would be increased to 800 mg/day. f) Water intake would be doubled.

a d e

What information would the nurse include when teaching postcircumcision care to the parents of a neonate? Select all that apply. a) Petroleum jelly or antibiotic ointment would be applied to the glans of the penis with each diaper change. b) The infant can have tub baths while the circumcision heals. c) Any amount of blood noted on the front of the diaper would be reported. d) The circumcision will require care for 2 to 4 days after discharge. e) The parent must note that the neonate has voided.

4 3 1 2 6 5

When teaching an antepartum client about the passage of the fetus through the birth canal during labor, the nurse describes the cardinal mechanisms of labor. Using a teaching pelvis and fetus, the nurse demonstrates which sequence during childbirth? Place these events in the proper sequence. All options must be used. 1. Internal rotation 2. Extension 3. Flexion 4. Descent 5. Expulsion 6. External rotation