maternity ati review
A nurse is teaching a client who had a vaccum-assisted vaginal delivery. which of the following statements should the nurse identify as an indication that the client understands the information ? a.my baby's head will be cone shaped for about 2 months b.my doctor performed this procedure because I didn't dilate past 6 cm c.the doctor performed this procedure because my hemoglobin was low d.my baby has a higher risk of developing jaundice
D
A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. which of the following pieces of information should the nurse provide ? a.you should slightly increase your exposure to sunlight b.you will need extensive dermatological treatment for this condition after you delivery your baby c.your provider will schedule weekly lab testing to monitor your liver function d.your provider will prescribe isotretinoin cream
A
A nurse is assisting with an amniotomy for a client who is in active labor. which of the following actions should the nurse take ? a. assess the fetal heart rate before and after the procedure b.monitor the client's temperature every 4 hr after the procedure c. medicate the client for pain 30 min prior to the procedure d.perform cervical assessments every 2 hr after the procedure
A
A nurse is caring for a client who is 32 hours postpartum. the client reports nipple soreness and breast engorgement. which of the following recommedations should the nurse provide ? a.call me so I can check your baby's latch the next time you breastfeed b.you should reduce the frequency of breastfeeding c.apply expressed breastmilk to sore nipples and cover them with nursing pads and a bra d.you should apply warm packs to the breast between nursing sessions
A
A nurse is caring for a client who is in labor and asks her partner to perform effleurage. the client. has on a monitor belt for electronic fetal monitoring. which of the following instructions should the nurse provide to the client's partner ? a.lightly stroke the upper thighs b.steadily apply pressure to the sacrum c.gently massage the mid-abdominal area d.firmly squeeze both hips
A
A nurse is caring for a client who is in labor and receiving IV oxytocin. the nurse notes contractions lasting 3 min each. what action should the nurse take? a.stop the oxytocin infusion b.apply oxygen at 2L/min via nasal cannula c.administer methyylergonovine IM d.prepare for an emergent cesarean birth
A
A nurse is providing nutritional counseling for a client who is pregnant. which of the following nutrients should the nurse instruct the client to increase in her daily diet ? a.iron b.calcium c.vitamin e d.vitamin k
A
A nurse is teaching a postpartum client how to swaddle her newborn. which of the following statements made by the parent demonstrates an understanding of the teaching ? a.i should stop swaddling my baby once she is able to roll over by herself b.my baby's legs should be extended straight out when I swaddle her c.i should be able to slide just 1 finger between my baby's chest and the swaddled blanket d.after swaddling, I should place my baby on her side in her crib or bassinet
A
Nurse creating a POC for patient who's postpartum and adheres to traditional Hispanic cultural beliefs. Which cultural practice should the nurse include in POC?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
a postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. the nurse should recommend that the client use which of the following breastfeeding positions ? a.side-lying b.clutch hold c.across-the-lap d.cross-cradle
A
A nurse is caring for several clients. which of the following clients should the nurse identify as a candidate for oral contraceptives ? a.a client who smokes 2 packs of cigarettes per week b.a client who Is breastfeeding a 7 month old infant c.a client who is taking an anticonvulsant medication d.a client who is taking anti-HIV protease inhibitors
B
A nurse is planning care for a client in active labor whose fetus is in an occipital brow presentation. which of the following complications should the nurse anticipate as a result of this fetal presentation ? a.precipitous labor b.prolonged labor c. hypertonic uterine dysfunction d.umbilical cord prolapse
B
A nurse is caring for a client who just had a spontaneous rupture of membranes. the nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. which of the following actions should the nurse take first ? a. place the client in an extreme trendelenburg position b.increase the iv fluid infusion rate c.manually apply upward pressure intravaginally on the presenting part d.administer 8 - 10L/min via a nonrebreather face mask
C
A nurse is teaching a client during the client's first prenatal visit. which of the following instructions should the nurse include ? a.a fetal sethoscope can first detect your baby's first heart rate at 22 weeks b.after week 16, we can see if your baby is a boy or girl c.a doppler device can detect your baby's heart rate at 12 weeks d. you will first feel the baby move at about 8 weeks
C
a nurse in an outpatient setting is providing education for a client who is pregnant. which of the following statements should the nurse include in the teaching ? a.durng the last trimester, you should mainly sleep on your back b.during the second trimester you will notice increased urinary frequency and urgency c.you will probably first notice your baby moving when you are around 20 weeks gestation d.you should plan to gain 40 to 45 pounds during your pregnancy
C
a nurse is assessing a client who is 2 days postpartum. in which of the following locations should the nurse expect to locate the client's fundus ? a. 3 cm above the umbilicus b.1 cm above the umbilicus c.3 cm below the umbilicus d.1 cm below the umbilicus
C
a nurse is assessing a newborn who was circumcised 24 hours ago. which of the following findings should the nurse report to the provider ? a. a scant amount of serosanguinoues drainage is noted in the newborn's diaper b. the newborn's circumcision is covered with yellow exudate c.the newborn has urinated once since the circumsion d.the newborn fusses during each diaper change
C
a nurse is assessing a newborn. for which of the following findings should the nurse notify the provider ? a.heart rate 136/min b.acrocyanosis c.mottling d.respiratory rate 60/min
C
a nurse is providing teaching for a client about hormonal changes during pregnancy. the nurse identifies that which of the following hormones plays a key role in preventing miscarriage ? a.oxytocin b.prolactin c.progesterone d.estrogen
C
a postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. which of the following interventions should the nurse take ? a.prepare to initiate a warm water sitz bath for the client's perineum b.encourage the client to sit on a soft pillow
C
while assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. which of the following findings should the nurse anticipate with bladder distention ? a. the fundus is at midline b. the fundus is below the umbilicus c.the bladder is resonant with percussion d.the bladder fluctuates with palpation
D
A nurse is performing a physical assessment of a full-term newborn and eliciting the moro reflex. which of the following movements are expected responses to this reflex. select all that apply a. thumb and forefinger forming a C b.legs extending before pulling upward c.arms and legs adducting d.arms falling backward after startling e.head turning to the right
AB
a nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. which of the following actions should the nurse implement after notifying the provider ? a. massage the fundus b.give oxygen at 2 L/min via nasal cannula c.administer oxytocin with IV fluids d.insert an indwelling urinary catheter e.place the client In a lateral position with her legs elevated 30 degrees
ACDE
a nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. which of the following responses indicates an understanding of the teaching ? a.i should call my provider if I develop melanoma b.if I notice that my eyes are puffy, I should call my provider c. I should call may provider if I notice that my feet and ankles are swollen d.if I notice periodic numbness and tingling in my fingers, I should call my provider
B
a nurse is assessing a client who delivered vaginally 8 hours ago. the nurse notes that the client's funds is 2 fingerbreadths above the umbilicus cord and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. which of the following actions should the nurse take first ? a. administer analgesia b.admnister carboprost IM c.assist the client to the tolet d.obtain a blood specimen to test Hct and HgB levels
C evidence-based practice indicates that the nurse should first help the client empty her bladder. displacement of the funds to the left indicates that the cause of the excessive bleeding is uterine atony due to bladder distension so this action is the nurse's priority
A nurse is assessing a newborn who has a congenital diaphragmatic Hernia. which of the following findings should the nurse expect? a.distended abdomen b.increased blood pressure c.generalized petechiae d.barrel-shaped chest
D
A nurse is caring for a client who is at 15 weeks of gestation, is rh-negative and has jus had an amniocentesis. which of the following interventions is the nurse's priority following the procedure ? a.observe the client's temperature b.observe the uterine contractions c.adminster RH immune globulin d. monitor the FHR
D
A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. which of the following client statement indicates an understanding of the teaching ? a.i should lightly massage my breasts when I feel discomfort b.i should express a small amount of milk if my breasts feel tight c.i should take a warm shower twice a day d. I should wear a support bra for a few days
D
Nurse is caring for patient that's 24 weeks gestation and has suspected placental abruption. Which lab test should the nurse expect the HCP to prescribe? a. Kleihauer-Betke test b.Progesterone serum level c.Lecithin/sphingomyelin (L/S) ratio d. Maternal Alpha-fetoprotein (AFP)
A
a nurse is performing an initial physical assessment of a newborn following a vaginal birth. which of the following findings should the nurse report to the provider ? a. small, pinpoint, reddish-purple spots on the chest b.bluish coloring of the feet c.overlapping suture lines d.white, cheese-like substance covering the skin
A
A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. which f the following condense should the nurse expect ? a.uterine rupture b.placental abrupt c.prolapsed umbilical cord d. amniotic fluid embolus
C
A nurse is teaching a client who is postpartum and breastfeeding. which of the following statements should the nurse include ? a. you all need two wait 3 months before resuming sexual intercourse b.you dont need to use contraception until you are 4 months postpartum c.as long as you breastfeed, you will experience an overproduction of vaginal lubrication d. a reduction in sexual intercourse could indicate postpartum depression
D
a nurse is assessing a client at 27 weeks of gestation. the client has placenta previa and reports vaginal bleeding. which of the following additional measures should the nurse expect ? a.the fundal height measures greater than gestational age b.a rigid abdomen is noted on palpation c.the client reports a pain level of 8 d.a urine drug screen is positive for cocaine
A
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation which of the following findings should the nurse report to the provider? a.fundal height 34 cm b.report of decreased fetal movement c.report of occasional ankle swelling d.BP 110/80
B
A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. which of the following actions should the nurse take ? a.request a prescription for preeclampsia laboratory studies b.advise the client to lie on her side c.request an ultrasund to evaluate fetal wellbeing d.advise the client to add a calcium supplement to her diet
B
A nurse is planning care for a client in labor who is positive for HIV. which of the following actions should the nurse take after the baby is born ? a.encourage the mother to breastfeed b.administer the hepatitis B vaccine prior to discharge c. implement contact and droplet precautions when providing care for the infant d.collect a cord blood specimen to test for the presence of HIV
B
A nurse is providing caret to a client who is 2 hours postpartum and is receiving an oxytocin IV. the client asks the nurse, "why is there so little bleeding?" which of the following responses should the nurse make? a a. this could indicate a possible uterine infection b. the bleeding is minimal until I discontinue your IV medication c.you might have retained some fragments of your placenta d.you will require additional medication to increase your bleeding
B
Nurse is assessing patient who's 1 day postpartum and has vaginal hematoma. Which manifestation should nurse expect?A.Lochia serosa vaginal drainage B.Vaginal pressure C.Intermittent vaginal pain D. yellow exudate vaginal drainage
B
a nurse Is caring for a client who is in labor and has received epidural analgesia. the client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. which of the following actions should the nurse take ? a. assist the client to the bathroom to empty her bladder b.increase the rate of primary IV infusion c.position the client in a semi-fowler's position d.provide glucose via oral hydration or IV
B
a nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. which of the following statements should the nurse make ? a.your provider will insert a hand into your uterus and turn your baby around b. you will receive a medication to relax your uterus prior t the procedure c.this procedure will be performed in the clinic at your next visit d.your baby's heartbeat will be monitored occasionally through the procedure
B
a nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. which of the following interventions should the nurse include. ? a.count the fetal heart rate for 15 seconds after contractions b.palpate and count the maternal radial pulse while listening to the fetal heart rate c.place the listening device over the fetal chest to hear the fetal heart rate d.percuss the maternal abdomen to verify the position of the fetus
B
a nurse is assessing a client who is 3 days postpartum. when examining the client's uterus, who of the following techniques should the nurse use ? a.press down and forward with the hand that is placed on the base of the uterus b.measure the height of the fundus in finger breadths in relation to the umbilicus c.place the client in a semi-fowler's position prior to checking the uterus d.massage the fundus with gentle palpation until it becomes soft to touch
B
a nurse is assessing a client who is pregnant and reports increased nasal stuffiness. the nurse should inform the client that which of the following hormones is responsible for this discomfort ? a.relaxin b.estrogen c.progesterone d.human chorionic somatomammmotropin
B
a nurse is caring for a client who had a vaginal delivery 24 hours ago. which of the following findings should the nurse report to the provider ? a. 2,000 mL urine since delivery b.3+ deep tendon reflexes c.fundus at umbilicus d.soft breasts
B
a nurse is caring for a client who is in active labor and whose birth plan request only nonpharamcological pain relief strategies. which of the following strategies should the nurse offer as a form of cutaneous stimulation ? a.breathing techniques b.counter-pressure c.biofeedback d.use of a focal point
B
a nurse is determining an Apgar score for a newborn who was born 1 min ago. for which of the following findings should the nurse assign a score of 1 ? a. HR 116/min b.weak cry c.flaccid muscles d.no response to stimuli
B
a nurse is monitoring a newborn who is receiving phototherapy. the nurse should identify which of the following findings as requiring intervention ? a.bilirubin level 5 mg/dl b.weight loss 12 % of birth weight c.loose, green stools d.axillary temperature of 36.6 C(97.9F)
B
a nurse is performing a non stress test on a client who is at 41 weeks of gestation. the client asks what is the purpose of the test. which of the following responses should the nurse make ? a. this test will determine if you are likely to deliver within the next week b.this test will help determine if your baby is healthy c. this test can see how your baby responds when you have contractions d.this test will determine if your baby's lungs are mature
B
a nurse is preparing to perform Leopold maneuvers on a client who is in labor. which of the following actions should the nurse plan to take ? a.ensure the client has a full bladder b.stand at the client's right side if the nurse is right-handed c.assist the client onto her back with knees extended d.palpate the outline of the fetus' head with the palms of the hands
B
a nurse is teaching a client about using the lamaze method to manage pain during labor. which of the following pieces of information should the nurse include ? a.learning about childbirth will reduce any fear you might have which will help focus more on abdominal breathing during contractions b.you will learn how to prevent pain during labor by focusing your mind to control your breathing. c.during labor, you will be encourage to disassociate by using an internal focal point d.during labor, you will use conscious relaxation and levels of progressive breathing
B
A nurse Is teaching a client who us in the third trimester of pregnancy and has herpes genitalis. which of the following instruction should the nurse include ? a.clean the lesions twice a day with hydrogen peroxide b.apply a hot compress to the affected areas c.talk with your doctor about a prescription for acyclovir to treat your symptoms d.expect to receive penicillin prior to delivery
C
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? a. give the client orange juice b.extend the client's legs c.have the client change positions d.establish IV access
C
A nurse is teaching a client about the use of nitrous oxide analgesia for pain control. which of the following statements by the client indicates an understanding of the teaching ? a.nitrous oxide could make my baby sleepy when he is born b.i should inhale the nitrous oxide almost immediately c.i will feel the effects of the nitrous oxide almost immediately d.nitrous oxide can make me feel disoriented
C
A nurse is teaching a newly liscensed nurse about collecting a specimen for the universal newborn screening. which of the following statements should the nurse include in the teaching ? a. obtain an informed consent prior to obtaining the specimen b.collect atleast 1ml of urine for the test c.ensure that the newborn has been receiving feedings for 24 hr prior to obtaining the specimen d.premature newborns may have false negative tests due to immature development of liver enzymes
C
a nurse is assessing a newborn. which of the following findings should the nurse report to the provider ? a.respiratory rate b.weight 2500 grams (5.5 lb) c.head circumference 28 cm(11 in) d.blood glucose 48 mg/dl
C
a nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline and located 1 cm below the umbillicus. which of the following actions should the nurse take? a.massage the funds b.instruct the client to empty her bladder c.notify the provider d.teach the client to perform a sitz bath
C
a nurse is assisting with an amniocentesis for a client who is rh-negative. which of the following actions should the nurse take following the procedure ? a.send a sample of amniotic fluid to screen the client for chlamydia b.send a sample of amniotic fluid to test for an elevated rh-negative titer c.adminster immune globulin to prevent fetal iso immunization d.adminsiter intravenous antibiotics to prevent an infection
C
a nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. which of the following actions should the nurse take to promote rotation of the fetal head ? a.apply counterpreessure to the client's back b.place the heat on the client's lower back c.instruct the client to squat during contractions d. encourage the Client to ambulate in the hall
C
a nurse is caring for a client who is in labor and is recieving an infusion of oxytocin. the nurse should monitor the client for which of the following potential adverse effects ? a.diarrhea b.thromboembolism c.fetal asphyxia d.oliguria
C
a nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. an assessment indicates 3cm dilation. which of the following actions should the nurse take ? a. encourage the client to bear down with contractions b.request a prescription to initate oxytocin c.offer the client hydrotherapy d.assist the client with ambulation
C
a nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). which of the following actions should the nurse take ? a.swaddle the infant with arms and legs extended b.administer naloxone IM c.avoid eye contact during feedings d.discourage the mother from handling the infant during the withdrawal phase
C
a nurse is planning care for a client who is postpartum and has cardiac disease. for which of the following prescriptions should the nurse seek clarification ? a. monitor the client's intake and output b.initiate a high-fiber diet for the client c.monitor the client's weight weekly d.intiate bedrest with the head of the bed elevated
C
a nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis. which of the following statements should the nurse include in the teaching ? A.an adverse effect of the medication is drowsiness b. this medication will require frequent monitoring of WBC levels c.use a soft toothbrush to brush your teeth gently d.avoid taking acetaminophen when taking this medication
C
a nurse is teaching a client about physiological changes that can occur with menopause. which of the following changes should the nurse include ? a.urinary hesitancy b.hematuria c.stress incontinence d.increased vaginal moisture
C
a nurse is teaching the guardian of a newborn about car seat safety. which of the following pieces of information should the nurse include ? a. position the child's car seat forward-facing at 1 year of age b.place the retainer clip 2 inches above the newborn's umbilicus c.place the shoulder harness in the slots that are level with the newborn's shoulders d.position the newborn's car seat at a 20 degree angle in the vehicle
C
a nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements ? a.prolactin is increasing the blood supply to the uterus and you are feeling blood vessel engorgement b.you probably have a small blood clot in your uterus which is causing the uterus to contract in order to expel it c.your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract d.the same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract
D
a nurse is providing teaching for a client at 7 weeks of gestation who is experiencing nausea and vomiting. which of the following client statements indicates to the nurse an understanding of the teaching ? a.i should eat fatty foods to increase my caloric intake b.i should brush my teeth right after eating c.acupressure bands on my elbows might help me feel better d. I should have a small snack before bedtime
D
a nurse is teaching a sibling class for a group of expectant parents and their older children. which of the following statements should the nurse include to facilitate sibling adaptation ? a. move the siblings out of their cribs and into beds 2 weeks prior to the baby's delivery b.consider having siblings play in another room when feeding your newborn c.have the sibling present during the discharge of newborn d.involve the sibling in decorating newborn's room
D