OB ATI Exam 3 ?s

A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. the newborn's birth weight is 1,100 g. which of the following are expected findings in this newborn? (select all that apply.) A. lanugo b. long nails C. weak grasp reflex d. translucent skin e. plump face

A. CORRECT: Characteristics of a preterm newborn include the presence of abundant lanugo. C. CORRECT: A weak grasp reflex is characteristic of a preterm newborn. d. CORRECT: skin that is thin, smooth, shiny, and translucent is a finding in a preterm newborn.

A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish marking across the newborn's lower back. the nurse should include which of the following information in the teaching? A. "this is frequently seen in newborns who have dark skin." b. "this is a finding indicating hyperbilirubinemia." C."this is a forceps mark from an operative delivery." D."this is related to prolonged birth or trauma during delivery."

A. CORRECT: mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and are of African American, Asian, or Native American origin.

A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. oxygen saturation b. body temperature C. serum bilirubin d. Heart rate

A. CORRECT: surfactant stabilizes the alveoli and helps increase oxygen saturation.

a nurse is assessing a client who has postpartum depression. the nurse should expect which of the following findings? (select all that apply.) a. Paranoia that her infant will be harmed B. Concerns about lack of income to pay bills C. anxiety about assuming a new role as a mother D. rapid decline in estrogen and progesterone e. Feeling of inadequacy with the new role as a mother

B. CORRECT: Feelings of financial inadequacy to provide for family is a finding associated with postpartum depression. C. CORRECT: anxiety about assuming a new role as a mother is a finding associated with postpartum depression. D. CORRECT: the rapid decline in estrogen and progesterone is a finding associated with postpartum depression. e. CORRECT: Feeling of inadequacies with the new role as a mother is a finding associated with postpartum depression.

a nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? a. a client who experienced a precipitous labor less than 3 hr in duration B. a client who had premature rupture of membranes and prolonged labor c. a client who delivered a large for gestational age infant D. a client who had a boggy uterus that was not well‐contracted

B. CORRECT: Premature rupture of membranes with prolonged labor poses the greatest risk for developing a postpartum infection because the birth canal was open, allowing pathogens to enter.

a client in the early postpartum period is very excited and talkative. She is repeatedly telling the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? a. Come back later when the client is more cooperative. B. Give the client time to express her feelings. C. Tell the client she needs to be quiet so the assessment can be completed. d. redirect the client's focus so that she will become quiet.

B. CORRECT: The nurse should recognize that the client in is the taking‐in phase, which begins immediately following birth and lasts a few hours to a couple of days.

a nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? a. "i will need to use contraception for 3 months before considering pregnancy." B. "i need a second vaccination at my postpartum visit." c."i was given the vaccine because my baby is o-positive." d."i will be tested in 3 months to see if i have developed immunity."

B. CORRECT: a second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity.

a nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? (select all that apply.) a. "I will perform peri care and apply a perineal pad in a back‐to‐front direction." B. "I will drink cranberry and prune juices to make my urine more acidic." c."I will drink large amounts of fluids to flush the bacteria from my urinary tract." D."I will go back to breastfeeding after I have finished taking the antibiotic." e. "I will take tylenol for any discomfort."

B. CORRECT: acidification of urine inhibits bacterial multiplication. c. CORRECT: Increased fluid intake can help to flush the bacteria from the urinary tract. e. CORRECT: acetaminophen is taken to reduce discomfort and pain associated with a urinary tract infection.

a nurse is caring for a client who is 2 days postpartum. The client states, "My 4‐year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? a. "your son was probably not ready for toilet training and should wear training pants." B. "your son is showing an adverse sibling response." C."your son may need counseling." d."you should try sending your son to preschool to resolve the behavior."

B. CORRECT: adverse responses by a sibling to a new infant can include regression in toileting habits.

a nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? a. a client who has an episiotomy that is erythematous and has extended into a third‐degree laceration B. a client who does not wash her hands between perineal care and breastfeeding C. a client who is not breastfeeding and is using measures to suppress lactation d. a client who has a cesarean incision that is well‐approximated with no drainage

B. CORRECT: the client who does not wash her hands between perineal care and breastfeeding is at an increased risk for developing mastitis. therefore, she is most at risk for developing a postpartum infection.

a nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? a. reinforce the need to take antipsychotics as prescribed. B. ask the client if she has thoughts of harming herself or her infant. C. monitor the infant for indications of failure to thrive. D. review the client's medical record for a history of bipolar disorder.

B. CORRECT: the nurse should identify that the greatest risk to the client and her infant is self‐harm or harm directed toward the infant. therefore, the priority action the nurse should take is to directly ask the client if she has thoughts of self‐harm, suicide, or harming the infant.

a nurse is assessing a postpartum client for fundal height, location, and consistency. the fundus is noted to be displaced laterally to the right, and there is uterine atony. the nurse should identify which of the following conditions as the cause of the uterine atony? a. Poor involution B. urinary retention c. hemorrhage d. infection

B. CORRECT: urinary retention can result in a distention of the bladder. a distended bladder can cause uterine atony and lateral displacement from the midline, usually to the right.

a nurse is providing discharge instructions to a postpartum client following a cesarean birth. the client reports leaking urine every time she sneezes or coughs. Which of the following interventions should the nurse suggest? a. sit‐ups B. Pelvic tilt exercises C. Kegel exercises d. abdominal crunches

C. CORRECT: Kegel exercises consist of the voluntary contraction and relaxation of the pubococcygeus muscle to strengthen the pelvic muscles, which will assist the client in decreasing urinary stress incontinence that occurs with sneezing and coughing.

A nurse is completing an assessment. which of the following data indicate the newborn is adapting to extrauterine life? (select all that apply.) A. expiratory grunting b. Inspiratory nasal flaring C. Apnea for 10‐second periods D. obligatory nose breathing e. Crackles and wheezing

C. CORRECT: Periods of apnea lasting less than 15 seconds are an expected finding. D. CORRECT: Newborns are obligatory nose breathers.

a nurse is caring for a newborn immediately following a circumcision using a gomco procedure. Which of the following actions should the nurse implement? a. apply gelfoam powder to the site. B. Place the newborn in the prone position. C. apply petroleum gauze to the site. d. avoid changing the diaper until the first voiding.

C. CORRECT: Petroleum gauze is applied to the site for 24 hr to prevent the skin edges from sticking to the diaper.

a nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? a. Front seat, rear‐facing B. Front seat, forward‐facing C. Back seat, rear‐facing d. Back seat, forward‐facing

C. CORRECT: The newborn should be restrained in a car seat in a rear‐facing position in the back seat until 2 years of age.

a nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? a. "his circumcision will heal within a couple of days." B. "i should remove the yellow mucus that will form." C."i will clean his penis with each diaper change." d."i will give him a tub bath within a couple of days."

C. CORRECT: The penis should be cleaned with warm water with each diaper change.

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. which of the following is the priority finding in the newborn? A. Conjunctivitis b. bronze skin discoloration C. sunken fontanels d. maculopapular skin rash

C. CORRECT: Using the safety and risk reduction framework, sunken fontanels is the priority finding. infants receiving phototherapy are at risk for dehydration from loose stools due to increased bilirubin excretion.

a nurse is providing discharge instructions for a client. at 4 weeks postpartum, the client should contact her provider for which of the following client findings? a. scant, nonodorous white vaginal discharge B. uterine cramping during breastfeeding C. sore nipple with cracks and fissures d. decreased response with sexual activity

C. CORRECT: a sore nipple that has cracks and fissures is an indication of mastitis.

A nurse is reviewing formula preparation with parents who plan to bottle‐feed their newborn. which of the following information should the nurse include in the teaching? (Select all that apply.) A. use a disinfectant wipe to clean the lid of the formula can. b. Store prepared formula in the refrigerator for up to 72 hr. C. Place used bottles in the dishwasher. D. Check the nipple for appropriate flow of formula. e. use tap water to dilute concentrated formula.

C. CORRECT: bottles can be placed in a dishwasher or washed by hand in hot soapy water using a good bottle brush. D. CORRECT: the flow of formula from the nipple should be checked to determine that it is not too fast or too slow. e. CORRECT: tap water is used to mix concentrated or powder formula. if the water is from a questionable source, it should be boiled first.

a nurse is taking a newborn to a mother following a circumcision. which of the following actions should the nurse take for security purposes? a. ask the mother to state her full name. b. Look at the name on the newborn's bassinet. C. Match the mother's identification band with the newborn's band. D. Compare name on the bassinet and room number.

C. CORRECT: each time the newborn is taken to the mother, the mother's identification band should be verified against the newborn's identification band.

a newborn was not dried completely after birth. which of the following mechanisms should the nurse understand causes heat loss? a. Conduction b. Convection C. evaporation D. radiation

C. CORRECT: evaporation is the loss of heat that occurs when a liquid is converted to a vapor. in a newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from the skin.

a nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. which of the following medications should the nurse anticipate administering? a. ofloxacin b. Nystatin C. erythromycin D. Ceftriaxone

C. CORRECT: one medication of choice for ophthalmia neonatorum is erythromycin ophthalmic ointment 0.5%. This antibiotic provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis.

A nurse is teaching a group of new parents about proper techniques for bottle feeding. which of the following instructions should the nurse provide? A. burp the newborn at the end of the feeding. b. Hold the newborn close in a supine position. C. Keep the nipple full of formula throughout the feeding. D. refrigerate any unused formula.

C. CORRECT: the nipple should always be kept full of formula to prevent the newborn from sucking in air during the feeding.

a nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these clinical findings? a. Postpartum fatigue B. Postpartum psychosis C. Letting‐go phase D. Postpartum blues

D. CORRECT: Postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and feeling let‐down.

a nurse is caring for a newborn immediately following birth. which of the following nursing interventions is the highest priority? a. initiating breastfeeding b. Performing the initial bath C. giving a vitamin K injection D. Covering the newborn's head with a cap

D. CORRECT: The greatest risk to the newborn is cold stress. Therefore the highest priority intervention is to prevent heat loss. Covering the newborn's head with a cap prevents cold stress due to excessive evaporative heat loss.

A nurse is giving instructions to a mother about how to breastfeed her newborn. which of the following actions by the mother indicates understanding of the teaching? A. the mother places a few drops of water on her nipple before feeding. b. the mother gently removes her nipple from the infant's mouth to break the suction. C. when she is ready to breastfeed, the mother gently strokes the newborn's neck with her finger. D. when latched on, the infant's nose, cheek, and chin are touching the breast.

D. CORRECT: effective latching‐on includes the infant's nose, cheek and chin touching the mother's breast.

A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. this finding is a characteristic of which of the following conditions? A. mongolian spots b. milia spots C. erythema toxicum D. epstein's pearls

D. CORRECT: epstein's pearls are small white nodules that appear on the roof of a newborn's mouth.

A nurse is reviewing breastfeeding positions with the mother of a newborn. which of the following positions should the nurse discuss? A. over‐the‐shoulder b. Supine C. Chin‐supported D. Cradle

D. CORRECT: the cradle position for breastfeeding includes the mother laying the newborn across her forearm with her hand supporting the lower back and buttocks.

A nurse is assessing the reflexes of a newborn. In checking for the moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. b. stimulate the pads of the newborn's hands with stroking or massage. C. stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi‐sitting position, then allow the newborn's head and trunk to fall backward.

D. CORRECT: the moro reflex is elicited by holding the newborn in a semi‐sitting position and then allowing the head and trunk to fall backward.

a nurse on the postpartum unit is planning care for a client who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? a. apply cold compresses to the affected extremity. B. massage the affected extremity. C. allow the client to ambulate. D. measure leg circumferences.

D. CORRECT: the nurse should plan to measure the circumference of the leg to assess for changes in the client's condition.

a nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. the client reports breast engorgement. Which of the following recommendations should the nurse make? a. "apply cold compresses between feedings." B. "take a warm shower right after feedings." C."apply breast milk to the nipples and allow them to air dry." d."use the various infant positions for feedings."

a. CORRECT: Cold compresses applied to the breasts after the feedings can help with breast engorgement.

a nurse is caring for a client who has disseminated intravascular coagulation (DiC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? a. Preeclampsia B. thrombophlebitis C. Placenta previa D. Hyperemesis gravidarum

a. CORRECT: DiC can occur secondary in a client who has preeclampsia.

a nurse is caring for a postpartum client who delivered her third infant 2 days ago. the nurse recognizes that which of the following findings are suggestive of postpartum depression? (select all that apply.) a. Fatigue B. insomnia C. euphoria D. Flat affect e. Delusions

a. CORRECT: Fatigue is a finding suggestive of postpartum depression. B. CORRECT: insomnia is a finding suggestive of postpartum depression. D. CORRECT: a flat affect is a finding suggestive of postpartum depression.

a nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? a. Staphylococcus aureus B. Chlamydia trachomatis c. Klebsiella pneumonia D. Clostridium perfringens

a. CORRECT: Staphylococcus aureus, Escherichia coli, and streptococcus are usually the infecting agents that enter the breast due to sore or cracked nipples, which results in mastitis.

a nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and mother‐infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) a. demonstrates apathy when the infant cries B. Touches the infant and maintains close physical proximity C. Views the infant's behavior as uncooperative during diaper changing d. identifies and relates infant's characteristics to those of family members e. interprets the infant's behavior as meaningful and a way of expressing needs

a. CORRECT: This behavior demonstrates a lack of interest in the infant and impaired maternal‐infant bonding. C. CORRECT: a client's view of her infant as being uncooperative during diaper changing is a sign of impaired maternal‐infant bonding.

a nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. which of the following responses should the nurse make to the newborn's mother regarding why this medication is given? a. "it assists with blood clotting." b. "it promotes maturation of the bowel." C."it is a preventative vaccine." D."it provides immunity."

a. CORRECT: Vitamin K is deficient in a newborn because the colon is sterile. until bacteria are present to stimulate vitamin K production, the newborn is at risk for hemorrhagic disease.

a nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep‐vein thrombosis (DVt). Which of the following clinical findings should the nurse expect? (select all that apply.) a. Calf tenderness to palpation B. mottling of the affected extremity C. elevated temperature D. area of warmth e. report of nausea

a. CORRECT: a client report of calf tenderness to palpation is an expected finding in a client who has a DVt. C. CORRECT: elevated temperature is an expected finding in a client who has a DVt. D. CORRECT: an area of warmth over the thrombus is an expected finding in a client who has a DVt.

a nurse is caring for a client who is postpartum. the nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? a. increasing pulse and decreasing blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. altered mental status and level of consciousness

a. CORRECT: a rising pulse rate and decreasing blood pressure are often the first indications of inadequate blood volume.

a nurse is caring for a client who is 1 hr postpartum following a vaginal birth and experiencing uncontrollable shaking. the nurse should understand that the shaking is due to which of the following factors? (select all that apply.) a. change in body fluids B. metabolic effort of labor c. diaphoresis d. decrease in body temperature E. decrease in prolactin levels

a. CORRECT: a shift in body fluids during the first 2 hr puerperium can cause a postpartum chill. B. CORRECT: the work of labor can cause a postpartum chill during the first 2 hr puerperium.

a nurse is discussing risks factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (select all that apply). a. epidural anesthesia B. urinary bladder catheterization c. frequent pelvic examinations D. History of UTIs e. Vaginal birth

a. CORRECT: epidural anesthesia is a risk factor for a utI. B. CORRECT: urinary bladder catheterization is a risk factor for a utI. c. CORRECT: a history of frequent pelvic examinations is a risk factor for a utI. D. CORRECT: a history of utIs is a risk factor for developing utIs.

a nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (select all that apply.) a. hypospadias B. hydrocele C. Family history of hemophilia d. hyperbilirubinemia e. epispadias

a. CORRECT: hypospadias involves a defect in the location of the urethral opening and is a contraindication to circumcision. C. CORRECT: a family history of hemophilia is a contraindication for circumcision. e. CORRECT: epispadias involves a defect in the location of the urethral opening and is a contraindication to circumcision.

a nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (select all that apply.) a. Precipitous delivery B. obesity C. inversion of the uterus D. oligohydramnios e. retained placental fragments

a. CORRECT: rapid, precipitous delivery is a risk factor for postpartum hemorrhage. C. CORRECT: inversion of the uterus in a risk factor for postpartum hemorrhage. e. CORRECT: retained placental fragments is a risk factor for postpartum hemorrhage.

a nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. she notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? a. moderate lochia rubra B. Excessive blood loss c. light lochia rubra d. scant lochia serosa

a. CORRECT: the client has moderate lochia rubra containing small clots, which is an expected finding for the second day postpartum.

a nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching? a. "Wear a supportive bra continuously for the first 72 hours." B. "Pump your breast every 4 hours to relieve discomfort." C."use breast shells throughout the day to decrease milk supply." d."apply warm compresses until milk suppression occurs."

a. CORRECT: the nurse should instruct the client to wear a well‐fitting support bra continuously for the first 72 hr.

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. "the newborn will have decreased muscle tone." b. "the newborn will have a continuous high‐pitched cry." C."the newborn will sleeps for 2 to 3 hours after a feeding." d."the newborn will have mild tremors when disturbed."

b. CORRECT: A continuous high‐pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome.

A nurse is caring for a newborn. which of the following actions by the newborn indicates readiness to feed? A. Spits up clear mucus b. Attempts to place his hand in his mouth C. turns his head toward sounds D. Lies quietly with his eyes open

b. CORRECT: readiness‐to‐feed cues include the newborn making hand‐to‐mouth and hand‐to‐hand movements, sucking motions, rooting, and mouthing.

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight b. Appropriate for gestational age C. small for gestational age D. Large for gestational age

b. CORRECT: this newborn is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile.

A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? a. "Limit the amount of time the infant nurses on each breast." B. "nurse the infant only on the unaffected breast until resolved." c."completely empty each breast at each feeding or use a pump." D."Wear a tight‐fitting bra until lactation has ceased."

c. CORRECT: Instruct the client to completely empty each breast at each feeding to prevent milk stasis, which provides a medium for bacterial growth.

during ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. on assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? a. Evidence of a possible vaginal hematoma B. an indication of a cervical or perineal laceration c. a normal postural discharge of lochia d. abnormally excessive lochia rubra flow

c. CORRECT: lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.

a nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? a. Cover the cord with a small gauze square. B. Trickle clean water over the cord with each diaper change. C. apply hydrogen peroxide to the cord twice a day. d. Keep the diaper folded below the cord.

d. CORRECT: Folding the diaper below the cord prevents urine from the diaper penetrating the cord site.

a nurse in the delivery room is planning to promote maternal‐infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. encourage the parents to touch and explore the neonate's features. B. limit noise and interruption in the delivery room. C. Place the neonate at the client's breast. D. Position the neonate skin‐to‐skin on the client's chest.

d. CORRECT: Placing the neonate in the en face position on the client's chest immediately after birth is the priority nursing intervention to promote maternal‐infant bonding

A nurse is caring for a client who is at 42 weeks gestation and in labor. the client asks the nurse what should she expect because her baby is postmature. which of the following statements should the nurse make? A. "Your baby will have excess body fat." b. "Your baby will have flat areola without breast buds." C."Your baby's heels will easily move to his ears." d."Your baby's skin will have a leathery appearance."

d. CORRECT: leathery, cracked, and wrinkled skin is seen in a newborn who is postmature due to placental insufficiency.

A nurse concludes that the father of an infant is not showing positive signs of parent‐infant bonding. He appears very anxious and nervous when the infant's mother asks him to bring her the infant. Which of the following actions should the nurse use to promote father‐infant bonding? a. Hand the father the infant, and suggest that he change the diaper. B. ask the father why he is so anxious and nervous. C. Tell the father that he will grow accustomed to the infant. d. Provide education about infant care when the father is present

d. CORRECT: nursing interventions to promote paternal bonding include providing education about infant care and encouraging the father to take a hands‐on approach.