Maternal Newborn ATI practice A
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
A newborn who is 18 hr. old and has an axillary temp. of 37.7 C (An axillary temp. greater than 37.5 C is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider)
A nurse is reviewing the 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
Hemoglobin 10 g/dL
a nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?
I will likely need to use alternative positions for sexual intercourse.
a nurse is providing teaching for a client gave birth 2 hours ago. The facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?
the person who comes to take my babies pictures will be wearing a photo identification badge
A nurse is planning care for a client who is to undergo a nonstress test.
you should press the handheld button when you feel your baby move
A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions?
~wipe the newborn's eyes from the inner canthis outward~wash the newborn's neck by lifting the newborn''s chin~cleanse the skin around the newborn's umbilical cord stump~wash the newborn's legs and feet~clean the newborn's diaper area
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening.
"Ensure that the newborn has been receiving feedings for 24 hours PRIOR to obtaining the specimen."Newborn screening mandated by law, do not need informed consent prior to obtaining newborn screening specimen.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which statement?
"I should take 600 micrograms of folic acid each day."
Nurse in an antepartum clinic is providing care for patient who's 26 weeks gestation. Upon review, which findings should the nurse report to HCP?
ANS: Fundal height measurement:
Nurse is performing a vag exam on a patient who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which actions should the nurse take?
ANS: Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.
Nurse caring for a patient that's 22 weeks gestation and is HIV positive. Which actions should the nurse take?
ANS: Report the client's condition to the local health department.:
Nurse is transporting newborn back to parent's room following procedure. Which actions should the nurse take?
ANS: Verify that the parent's ID band matches the newborn's ID band:
Nurse performing physical assessment of a newborn upon admission to nursery. Which manifestations should the nurse expect? (SATA)
Acrocyanosis, Positive babinski reflex, two umbilical arteries visible
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 take immediately after the seizure?
Administer oxygen via a nonrebreather mask
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?
BUN 25 mg/dL
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
Begin FHR monitoring
A nurse is caring for a client who is at 36 weeks gestation and has a positive contraction stress test. The nurse should plan the client for which of the following next diagnostic test?
Biophysical profile - a positive contraction stress test means more further evaluation of the fetus is necessary, and a biophysical profile will provide further evaluation of real time ultrasound
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?
Blurred vision
Nurse caring for patient who's experiencing preeclampsia and has a new prescription for IV mag sulfate. Which meds should the nurse anticipate adm. if client develops mag toxicity?
Calcium gluconate
Nurse giving teaching about nonpharm pain management to patient who's breastfeeding and has engorgement. Nurse should recommend application of which items?
Cold cabbage leaves
Nurse in an antepartum clinic is assessing a patient who is at 32 weeks gestation. Which findings should the nurse report to HCP?
Decreased fetal movement
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?
Depression
A nurse is performing a routine assessment on a pt who is 18 weeks. What should the nurse expect?
FHR of 152/min
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect. (select all that apply)
HR of 154/min RR of 58/min Wt 2.6 kg (5 lb 12 oz)
A nurse is caring for a client who is at 35 weeks gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?
Have the client change positions
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?
I can administer oxytocin 4 hours after the insertion of the medication
A nurse is assessing a newborn 12 hours after birth. Which should be reported to the provider?
Jaundice
A nurse is caring for a client who is receiving heparin bc of thrombophlebitis on the left calf. Which of the following actions should the nurse take?
Keep the client on bedrest - having her walk might break off and dislodge the clot elsewhere - like a pulmonary embolism.
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
Kleihauer-Betke test
A nurse is caring for a client who is to receive oxytocin to augment her labor. which of the following findings contraindicates the initiation of the oxytocin infusion and requires notification of the provider
Late decelerations
A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother nurse recognize as a positive parenting behavior?
Lays the newborn across her lap and gently sways
A nurse is caring for a client at 36 weeks and has a perscription for an amniocentesis. Why should the client get an ultrasound before hand?
Locate a pocket of fluid
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?
Massage the client's fundus
A nurse is assessing a newborn who is 26 week pregnant using the new ballard score. Which of the following findings should the nurse expect?
Minimal arm recoil
a nurse is caring for a client who is 15 weeks of gestation, is Rh negative, and just had an amniocentesis. Which of the following interventions is the nurses priority following the procedure?
Monitor FHR
a nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse include in the plan?
Monitor FHR continuously
Nurse is assessing patient who's receiving morphine via IV bolus for pain following c-section. Nurse notes RR of 8/min. Which meds should the nurse administer?
Naloxone
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers?
One with hands on top of the uterus
A nurse is caring for a patient that's 32 weeks gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?
PROM
Before placing an external transducer to monitor fetus on patient. who is 38 weeks pregnant. What should the nurse do?
Perform Leopold manuvers
A nurse is in postpartum caring for a client who has traditional hispanic beliefs. What should the nurse prepare to do that matches those beliefs?
Protect the clients head and feet from cold air.
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
RR 10/min
A nurse is developing a plan of care for a newborn who has to undergo phototherapy due to hyperbilirubinemia
Remove all clothing from the newborn except the diaper
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect
Reports increased urinary output
a nurse is assessing a late preterm. Which of the following clinical manifestation is an indication of hypoglycemia?
Respiratory distress
A nurse is caring for a client who has parvovirus B19 (fifth disease), which of the following actions should the nurse take?
Schedule an ultrasound examination
Nurse is assessing a newborn who is 16 hr old. Which findings should the nurse report to HCP?
Substernal retractions
A nurse in a prenatal clinic is assessing a group of pts. Which of the following pts. should the nurse request the provider see first?
The client who is 11 weeks and reports abdominal cramping - which could be a sign of miscarriage or ectopic pregnancy.
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?
Vaginal pressure
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?
Wt gain of 2.2kg (4.8 lb)
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 ?
You can still become pregnant if you are breastfeeding.
A nurse is assessing a client who received carboprost for PP hemorrhage, Which of the following findings is an adverse effect of this medication
hypertension
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 7 year old child child and accept the new family member?
obtain a gift from the newborn to present to the sibling.
A nurse is preparing to collect a blood specimen for 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
place the newborn skin to skin on the mother's chest
a nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
pregestational diabetes mellitus
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider
visual disturbances