ATI Maternal Newborn OB

Nurse is teaching patient of 37 weeks gestation and has a prescription for a nonstress test. Which instructions should the nurse include? -Test should take 10-15 min to complete -You will lay in supine position throughout the test -You should not eat or drink for 2 hours before the test -You should press the handheld button when you feel your baby move

-You should press the handheld button when you feel your baby move

A nurse in a prenatal clinic is assessing a group of patients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

ANS: A client who is at 11 weeks of gestation and reports abdominal cramping:- When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand:- is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. Therefore, there is another client that the provider should see first. A client who is at 20 weeks of gestation and reports constipation for the past 4 days:- nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week- Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is another client that the provider should see first.

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test

ANS: Biophysical profile:- A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. Amniocentesis:- An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. Cordocentesis:- A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. Kleihauer-Betke test:- used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed

ANS: Respiratory rate 10/min:- The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Client reports nausea:- Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. Urinary output of 40 mL/hr:- Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider .Client reports feeling flushed:- Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures.

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in)

ANS: Substernal retractions:- The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. Acrocyanosis:- an expected finding in the newborn for the first 24 hr following birth. Overlapping suture lines:- Overlapping suture lines with molding are an expected variation for newborns who were delivered vaginally. Head circumference 33 cm (13 in):- A head circumference of 33 cm is within the expected reference range for a newborn following birth.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. Wrap the visible cord tightly with sterile, dry gauze. Apply oxygen to the client at 2 L/min via nasal cannula. Place the client in the lithotomy position and apply fundal pressure.

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. Restrict the total hourly intake to 200 mL. Monitor the FHR continuously. Administer protamine sulfate for manifestations of toxicity.

Monitor the FHR continuously.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.

Perform Leopold maneuvers.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible

Positive Babinski reflex Two umbilical arteries visible Acrocyanosis

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus

Pregestational diabetes mellitus

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? Excessive bleeding Oligohydramnios Premature rupture of membranes Proteinuria

Premature rupture of membranes

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions

Weight gain of 2.2 kg (4.8 lb)