ATI Maternal Final
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?
480 mL urine output in 24 hr
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. Which of the following laboratory tests will be used to confirm the clients pregnancy?
A urine test for the presence of human chorionic gonadotropin
A nurse is assessing a client on the first postpartum day. Findings include the following: fundus form and one finger breath about and to the right of the umbilicus, moderate loggia rubra with small clots, temperature 37.3C (99.2F), and pulse rate 52/min. Which of the following actions should the nurse take?
Ask the client when she last voided
A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take?
Assist the client to ambulate in the hallway
A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client temperature is 100F and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulance and no bowel movement since delivery. Which of the following actions should the nurse take?
Assist the client to empty her bladder
A nurse is planning care for a client who is pregnant and is Rh negative . In which of the following situations should the nurse administer Rh(D) immune globulin?
At 28 weeks gestation
A nurse is caring for a client who is experiencing prolonged labor. Which of the following fetal monitoring results indicates fetal compromise?
Late deceleration with fetal bradycardia
A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observed fetal bradycardia on the FHR racing and a prolapsed umbilical cord. Which of the following actions should the nurse take first?
Manually apply upward pressure intravaginally on the presenting part
a nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device?
Menorrhagia
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?
Palpable fetal movement
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?
Progesterone
A nurse is caring for a client who is in labor and has fetal heart tracings of variable decelerations. Which of the following actions should the nurse take?
Reposition the client from side to side
A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?
Slow-paced breathing
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?
The bladder fluctuates with palpation
A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should identify the provider about which of the following assessment findings?
The client reports a frequent cough
A nurse is caring for a primigravida client who is at 8 weeks gestation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make?
There feelings are quite normal at the beginning of pregnancy
A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider?
There is decreased abdominal movement with breathing
A nurse is caring for a client who asks, "how will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make?
True contractions will begin irregularly and then become regular in timing
A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect?
Urinary retention
A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record?
Vertex
a nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take?
assess the newborn for respiratory depression
A nurse is caring for a client who is at 38 wks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contraction. Which of the following actions should the nurse take?
assist the client to a lateral position
a nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first?
assist the client to the bathroom
a nurse in a prenatal clinic is performing telephone triage for several clients. which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy?
breast tenderness
a nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take?
continue monitoring newborn
a nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. which of the following findings is a risk factor for an ectopic pregnancy?
pelvic inflammatory disease (PID)
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?
prolonged labor
a nurse is caring for a client who is in the first trimester of pregnancy and asked how to manage heartburn. which of the following responses should the nurse make?
reduce the amount of food you eat during meals
a nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). which of the following statements should the nurse include in the teaching?
you should continue to take zidovudine throughout the pregnancy
A nurse is teaching a parent of a newborn how to care for the newborns umbilical cord stump. Which of the following instructions should the nurse includes?
Clean the cord stump with tap water
A nurse is caring for a client during her first prenatal visit and notes that she is lactose-intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?
Collard greens
A nurse is teaching a client who is at 12 weeks gestation about manifestation of potential complications that she should report to her provider. Which of the following pieces of information should the nurse include in the teaching
Facial swelling
A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presences of meconium-stained fluid. Which of the following actions should the nurse take?
Gather equipment for neonatal resuscitation
A nurse is caring for a client who has eclampsia and just had a tonic clonic seizure. After turning the clients head to the side, which of the following actions should the nurse take next?
Give oxygen at 10 L/min via face mask
A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions?
Giving the hepatitis B vaccine
A nurse is caring for a client who is 24 years old and at 13 weeks of gestational. The client history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38g (9lb 3oz). Which of the following laboratory values should the nurse expect to collect?
HbA1c
A nurse is talking with a client at 20 weeks of gestation who is scheduled for a sonogram. The client states "I am here to have my regular prenatal checkup, but I do not want any pictures taken if my baby." Which of the following responses should the nurse make?
I would like to hear more about why you don't want the sonogram, including any cultural reasons
A nurse is caring for a client who delivered a stillborn child. Which of the following actions should the nurse take?
Allow the parents to keep the child in their room for as long as the wish
A nurse is assessing a female client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take?
Ambulate the client to the bathroom
A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching?
Carbohydrates should make up 55% of your diet