Maternal ATI

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A. "I can administer oxytocin 4 hrs after the insertion of the med" B. "You will need a full bladder prior to the insertion of the med" C. "Remain in a side-lying position for 15 mins after the med is inserted" D. An antacid will be given 20 mins prior to the insertion of the med"

A. "I can administer oxytocin 4 hours after the insertion of the medication"

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A. A client who is at 11 weeks of gestation and reports abdominal cramping B. A client who is at 15 weeks gestation and reports tingling and numbness in right hand C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days D. A client who is at 8 weeks of gestation and reports having 3 bloody noses in the past week

A. 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

A nurse in a clinic is caring for a 16 yo adolescent. Which of the following findings should the nurse report to the provider? SATA A. Abdominal assessment B. Vaginal discharge C. Heart rate D. Temperature E. Dyspareunia F. Condom usage

A. Abdominal assessment B. Vaginal discharge D. Temperature E. Dyspareunia F. Condom usage

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? A. Abruptio placenta B. Placenta previa C. Preeclampsia D. Maternal bradycardia

A. Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. which of the following findings should the nurse report to the provider? A. BUN 25 mg/dL B. Serum creatinine 0.8 mg/dL C. Urine output of 280 mL within 8 hr D. Urine negative for ketones

A. BUN 25 mg/dL Elevated - indicate dehydration

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? A. Biophysical profile B. Amniocentesis C. Cordocentesis D. Kleihauer-Betke test

A. Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? A. Calcium gluconate B. Hydralazine C. Medroxyprogesterone acetate D. Methylergonovine

A. Calcium gluconate Calcium gluconate is the antidote for magnesium toxicity

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommended the application of which of the following items? A. Cold cabbage leaves B. Purified lanolin cream C. A snug-fitting support bra D. Breast shells

A. Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve pain associated with engorgement

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? A. Depression B. Polyuria C. Hypotension D. Urticaria

A. Depression

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? A. Hemoglobin 10g/dL B. WBC count 10,000/mm3 C. Platelets 250,000/mm3 D. Fasting blood glucose 90 mg/dL

A. Hemoglobin 10g/dL Below expected reference range of greater than 11 g/dL for a client who is pregnant

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? A. Hypertension B. Hypothermia C. Constipation D. Muscle weakness

A. Hypertension The nurse recognize that carboprost is a vasoconstrictor that can cause hypertension

A nurse is performing a vaginal exam 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? A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part B. Wrap the visible cord tightly with sterile, dry gauze C. Apply oxygen to the client at 2 L/min via nasal cannula D. Place the client in the lithotomy position and apply fundal pressure

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

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin ratio D. Maternal Alpha-fetoprotein (AFP)

A. Kleihauer-Betke test Determines if fetal blood is in maternal circulation

A nurse is caring for a client who is receiving oxytocin to augment her labor. Which of the following findings CI the initiation of the oxytocin infusion and should be reported to the provider? A. Late decelerations B. Moderate variability of the FHR C. Cessation of uterine dilation D. Prolonged active phase of labor

A. Late decelerations They are indicative of uteroplacental insufficiency

A nurse is observing a new parent caring for their crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? A. Lays the newborn across their lap and gently sways B. Places the newborn in the crib in a prone position C. Offers the newborn a pacifier dipped in formula D. Prepares a bottle of formula mixed with rice cereal

A. Lays the newborn across their lap and gently sways This is the correct technique for quieting a newborn

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? A. Minimal arm recoil B. Popliteal angle of 90 degrees C. Crease over the entire foot sole D. Raised areolas with 3-4 mm buds

A. Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? A. Protect the client's head and feet from cold air B. Bathe the client within 12 hr following birth C. Ambulate the client within 24 hr following birth D. Offer the client a glass of cold milk with her first meal

A. Protect the client's head and feet from cold air

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? A. Reports increased urinary output B. Diaphoresis C. Reports blurred vision D. Shallow respirations

A. Reports increased urinary output

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? A. Verify that the parent's identification band matches the newborn's B. Scan the newborn's ID band to verify identity C. Check the newborn's security tag number to ensure it matches med-record D. Match the newborn's date/time of birth with info in parent's med-record

A. Verify that the parent's identification band matched the newborn's

Gonorrhea consistent signs

Abdominal pain, greenish discharge, pain on urination, absence of condom use

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding the newborn should the nurse anticipate? SATA A. Instruct the mother to discontinue breastfeeding B. Administer scheduled dose of oral morphine C. Give a one-time dose of naloxone IM D. Maintain low-stimulus environment E. Initiate NAS scoring

B. Administer scheduled dose of oral morphine D. Maintain low-stimulus environment E. Initiate NAS scoring

A nurse is providing teaching to a client about the physiological change that occur during pregnancy. The client is at 10 weeks gestation. A. "I will not gain more than 15-20 pounds during pregnancy" B. "I will likely need to use alternative positions for sexual intercourse" C. "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy" D. "I'm glad I have a light complexion and will not get any stretch marks"

B. "I will likely need to use an alternative position for sexual intercourse"

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? SATA A. Yellow sclera B. Acrocyanosis C. Posterior fontanel larger than the anterior fontanel D. Positive Babinski reflex E. Two umbilical arteries visible

B. Acrocyanosis D. Positive Babinski reflex E. Two umbilical arteries visible

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? A. Determine progression of dilation and effacement B. Perform Leopold maneuvers C. Complete a sterile speculum exam D. Prepare a Nitrazine paper test

B. Perform Leopold maneuvers To assess the position of the fetus to best determine the optimal placement for the external fetal monitor

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication B. Schedule an ultrasound examination C. Administer Haemophilus influenzae type b vaccine D. Schedule an indirect Coombs' test

B. Schedule an ultrasound examination To monitor the fetus during the pregnancy to detect the possible development of fetal hydrops

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocenteses. For which of the following reasons should the nurse prepare the client for an ultrasound? A. To estimate the fetal weight B. To locate a pocket of fluid C. To determine multiparity D. To prescreen for fetal anomalies

B. To locate a pocket of fluid This decreases the risk of injury to the fetus

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. the nurse include in the teaching? A. "Obtain an informed consent prior to obtaining the specimen" B. "Collect at least 1 milliliter of urine for the test" C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen D. "Premature newborns may have false negative tests due to immature development of liver enzymes"

C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen"

A nurse is providing teaching for a client who gave birth 2 hrs ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? A. "My sister will be able to carry my baby from the nursery to my room when she arrives" B. "The nurse will match my wrist band to my baby's crib card when they bring him to me" C. "The person who comes to take my baby's pictures will be wearing a photo identification badge"

C. "The person who comes to take my baby's pictures will be wearing a photo identification badge"

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? A. "You can resume sexual activity in 1 week" B. "You won't need to do Kegel exercises since you had a cesarean" C. "You can still become pregnant if you are breastfeeding" D. "You are safe to start adding sit-ups to your exercise routine in 2 weeks"

C. "You can still become pregnant if you are breastfeeding"

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? A. Decreased uterine contractions B. An increase in the client's hemoglobin levels C. A reduction in respiratory distress in the newborn D. Increased production of antibodies in the newborn

C. A reduction in respiratory distress in the newborn Glucocorticoid that stimulate fetal lung maturity

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse immediately after the seizure? A. Monitor the FHR B. Assess uterine activity C. Administer oxygen via a nonrebreather mask D. Start a bolus of IV fluids

C. Administer oxygen via a nonrebreather mask When using the ABCs of patient care, the nurse should place priority on administering oxygen to ensure adequate oxygenation to the fetus

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? A. Elevated temperature B. Boggy uterus C. Client report of vaginal pain D. Client report of yellow exudate vaginal drainage

C. Client report of vaginal pain Due to localized swelling

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? A. Acrocyanosis B. Transient strabismus C. Jaundice D. Caput succedaneum

C. Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization.

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? A. Fentanyl B. Butorphanol C. Naloxone D. Meperidine

C. Naloxone

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7yo child in accepting the new family member? A. Allow the sibling to hold the newborn during a bath B. Make sure the sibling kisses the newborn each night C. Obtain a gift from the newborn to present to the sibling D. Switch the sibling's room with the nursery

C. Obtain a gift from the newborn to present to the sibling

A nurse is assessing a newborn who was delivered vaginally and experience a tight nuchal cord. Which of the following findings should the nurse expect? A. Bruising over the buttocks B. Hard nodules on the roof of the mouth C. Petechiae over the head D. Bilateral periauricular papilloma

C. Petechiae over the head Nuchal cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head and neck

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? A. Feed the newborn 1 oz of water every 4 hr B. Apply lotion to the newborn's skin three times a day C. Remove all clothing from the newborn except the diaper D. Discontinue therapy if the newborn develops a rash

C. Remove all clothing from the newborn except the diaper

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? A. Client reports nausea B. Urinary output of 40 mL/hr C. Respiratory rate 10/min D. Client reports feeling flushed

C. Respiratory rate of 10/min

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? A. Blood pressure 136/88 mm Hg B. Report of insomnia C. Weight gain of 2.2 kg (4.8 lb) D. Report of Braxton Hicks contractions

C. Weight gain of 2.2 kg (4.8 lb) Above expected reference range and could indicate complications

The nurse is planning care for the adolescent. Which of the following prescriptions should the nurse expect the provider to prescribe?

Ceftriaxone and doxycycline Ceftriaxone is an anti-infective Doxycycline is an anti-infective

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should increase my protein intake to 60 grams each day" B. "I should drink 2 L of water each day" C. "I should increase my overall daily caloric intake by 300 calories" D. "I should take 600 micrograms of folic acid each day"

D. "I should take 600 micrograms of folic acid each day" Folic acid assists with preventing neural tube birth defects

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A. A newborn who is 26 hrs old and has erythema toxicum on his face B. A newborn who is 32 hr old and has not passed a meconium stool C. A newborn who is 12 hr old and has pink-tinged urine D. A newborn who is 18 hr old and has an axillary temp of 37.7 C (99.9F)

D. A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F)

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? A. Perform Nitrazine testing B. Assess the fluid C. Check cervical dilation D. Begin FHR monitoring

D. Begin FHR monitoring The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? A. Deep tendon reflexes 4+ B. Fundal height 14 cm C. Urine protein 2+ D. FHR 152/min

D. FHR 152/min Expected FHR 160/min at 20 weeks of gestation

A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following intervention is the nurse's priority following the procedure? A. Check the client's temperature B. Observe for uterine contraction C. Administer Rho(D) immune globulin D. Monitor the FHR

D. Monitor the FHR

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A. Apply a cool pack for 10 min to the heel prior to the puncture B. Request a prescription for IM analgesic C. Use a manual lance blade to pierce the skin D. Place the newborn skin to skin on the mother's chest

D. Place the newborn skin to skin on the mother's chest Effective technique to significantly decrease the newborn's pain level and anxiety.

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? A. Singleton pregnancy B. BMI of 20 C. Maternal age of 32 years D. Pre-gestational diabetes mellitus

D. Pre-gestational diabetes mellitus

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? A. Hypertonia B. Increased feeding C. Hyperthermia D. Respiratory distress

D. Respiratory distress Other manifestations: abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures

Candidiasis consistent signs

Diabetes, pain on urination, absence of condom use

Trichomoniasis consistent signs

Greenish discharge, pain on urination, absence of condom use

The nurse is reviewing the provider's prescriptions in the adolescent's medical chart. The nurse should first implement ____ and ____

Providing education on medication; administering ceftriaxone

The nurse is reviewing the adolescent's medical record. Which of the following conditions in the client most likely developing?

The adolescent is most likely developing Pelvic Inflammatory Disease as evidenced by C-reactive protein

Correct order of bathing baby

Wipe eyes from inner canthus outward -> wash neck by lifting the chin -> cleanse skin around umbilical cord stump -> wash legs and feet -> clean diaper area