ATI Maternal Newborn 2023 Proctored Exam
A nurse is caring for a 2-day-old newborn who was born t 35 weeks gestation. Which of the following actions should the nurse take?
D. Insert an orogastric decompression tube with low wall suction
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care? A. Increase the newborn's visual stimulation B. Weigh the newborn every other day C. Discourage parental interaction until after a social evaluation D. Swaddle the newborn in a flexed position
D. Swaddle the newborn in a flexed position Swaddling in a flexed position with hands midline against chest and legs loosely swaddled in lumbar flexion to decrease sensory stimulation. Minimize environmental and physical stimulation low lighting and noise level do not use TV or mobiles. Avoidance of abrupt changes in infant's environment handle gently and close to the body to increase sense of security.
A nurse in a provider's office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Nagele's rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
12/15
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should position my baby's car seat at a 45-degree angle in the car." B. "I should place the car seat rear facing until my baby is 12 months old." C. "I should place the harness snugly in a slot above my baby's shoulders." D. "I should position the retainer clip at the top of my baby's abdomen."
A. "I should position my baby's car seat at a 45-degree angle in the car." Set the seat at a 45-degree angle. Your baby's head should rest at least 2 inches below the top of the car seat.
A nurse is assessing a client who is at 37 weeks (about 8 and a half months) of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. "It burns when I urinate." B. "My feet are really swollen today." C. "I didn't have lunch today, but I have breakfasted this morning." D. "I have been seeing spot this morning."
A. "It burns when I urinate."
A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. "It burns when I urinate." B. "My feet are really swollen today." C. "I didn't have lunch today, but I have breakfasted this morning." D. "I have been seeing spot this morning."
A. "It burns when I urinate." During pregnancy, you're more susceptible to urinary tract infections. Most commonly, such infections are confined to the bladder, when they are known as cystitis. Symptoms of cystitis include a frequent, urgent need to urinate and a painful burning sensation when passing urine; there may be some blood in your urine.
A nurse is assessing a 2-day newborn and notes an egg-shaped, edematou, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment" B. "This will resolve on its own within 3 to 4 days" C. " The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you dont need to worry."
A. "This will resolve in 3 to 6 weeks without treatment" This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
A. "Transmission can occur via the saliva and urine of the newborn"
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make? A. "You can bathe and dress your baby if you'd like to." B. "If you don't hold the baby, it will make letting go much harder." C. "You should name the baby so she can have an identity." D. "I'm sure you will be able to have another baby when you're ready."
A. "You can bathe and dress your baby if you'd like to." Offer the parents the choice of holding the infant in their arms.
A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching? A. "You should feel a tugging (pulling) sensation when the baby is sucking. B. You should expect your baby to have two to three wet diapers in 24 hours period C. "Your baby's urine should appear dark and concentrated". D. "Your breast should stay firm after the baby breastfeeds".
A. "You should feel a tugging (pulling) sensation when the baby is sucking. Firm tugging sensation on nipple as infant sucks but no pain. Has at least three substantive bowel movements and six to eight wet diapers every 24 hours after day 4.
A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which 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 adter you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."
A. "You should slightly increase your exposure to sunlight." Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching.
A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make? A. "You will need to stay in a side-lying position for 30 minutes after each dose." B. "You will receive an IV infusion of oxytocin 1 hour after your last dose." C. "You will receive a magnesium supplement immediately following therapy." D. "You will need to have a full bladder before the therapy begins."
A. "You will need to stay in a side-lying position for 30 minutes after each dose." Assist the woman to maintain a supine position with a lateral tilt or a side-lying position for 30 to 40 minutes after insertion. Initiate oxytocin for induction of labor no sooner than 4 hours after the last dose of misoprostol was administered, following agency protocol, if ripening has occurred and labor has not begun.
A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization? A. A Rh-negative mother who has a Rh-positive infant B. A Rh-positive mother who has a Rh-negative infant C. A Rh-positive mother who has a Rh-positive infant D. A Rh-negative mother who has a Rh-negative infant
A. A Rh-negative mother who has a Rh-positive infant Rho(D) immune globulin is used to prevent antibodies from forming when a mother has Rh- negative blood and the baby is Rh-positive so that antibodies from the mother that crosses the placenta and attacks fetal blood cells causing hemolysis.
A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (select all that apply). A. Amnionitis B. Urinary tract infection C. Polyhydramnios D. Leakage of amniotic fluid E. Preterm labor
A. Amnionitis D. Leakage of amniotic fluid E. Preterm labor Amniocentesis is a well-known procedure performed during pregnancy for diagnostic and therapeutic purposes. Typical complications of the procedure include infection of the amniotic sac, preterm labor, respiratory distress, fetal deformities, trauma, alloimmunization, and failure of the puncture wound to heal properly.
A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort? A. Assisting the client into squatting position B. Having the client lie in a supine position C. Applying fundal pressure during contractions D. Encouraging the client to void every 6 hrs.
A. Assisting the client into squatting position
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hrs. postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? A. Blood pressure 142/92 mm Hg B. Urine output 100 mL in hr. C. Pulse 58/min D. Respiratory rate 14/min
A. Blood pressure 142/92 mm Hg Presence of other medical problems such as HTN contraindicates with methylergonovine. Because methylergonovine is vasoconstrictive, monitor patient's blood pressure, heart rate, and uterine response prior to and during administration.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider? A. Contraction durations of 95 to 100 seconds B. Contraction frequency of 2 to 3 min apart C. Absent early deceleration of fetal heart rate D. Fetal heart rate is 140/min
A. Contraction durations of 95 to 100 seconds For a normal uterine activity during labor contraction duration remains fairly stable throughout first and second stages, ranging from 45-80 seconds, not generally exceeding 90 seconds.
A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include? A. Focusing on controlling body functions B. "Synchronized breathing will be required during hypnosis" C. "Hypnosis can be beneficial in you practiced it during the prenatal period" D. "Hypnosis does not work for controlling pain associated with labor".
A. Focusing on controlling body functions Hypnosis techniques used for labor and birthplace an emphasis on enhancing relaxation and diminishing fear, anxiety, and perception of pain. Women using this technique report a greater sense of control over painful contractions and a higher level of satisfaction with their childbirth experience.
A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? a.Hemoglobin 12 g/dL. b.Glucose 50 mg/dL. c.Bilirubin 4 mg/dL. d.Platelets 200,000/mm³.
A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL.
A nurse is reviewing laboratory results for client who is pregnant. The nurse should expect which of the following laboratory values to increase? A. RBC count B. Bilirubin C. Fasting blood glucose D. BUN
A. RBC count RBC count increases from million/mm3 4.2-5.4 to 5-6.25 million/mm3 during pregnancy.
A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching? A. Hepatitis B B. Rotavirus C. Pneumococcal D. Varicella
A. Hepatitis B Hepatitis B immunization is recommended at birth, 1 to 2 months, and between 6 to 18 months. It is injected intramuscularly soon after birth. For newborns born to hepatitis- infected mothers, hepatitis B immune globin (HBIG) also should be administered within 12 hrs. of birth. The vastus lateralis is the preferred site of intramuscular injections in newborns, and no more than 0.5 mL should be administered in one injection. Shortly after birth, your baby should receive the first dose of the vaccine to help protect against the following disease: Hepatitis B and 1-month later RV, DTap, Hib, PCV13, & IPV.
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? A. Increase the infusion rate every 30 to 60 min. B. Maintain the client in a supine position. C. Titrate the infusion rate by 4 milliunits/min. D. Limit IV intake to 4 L per 24 hr.
A. Increase the infusion rate every 30 to 60 min. Traditional protocols for oxytocin infusion regimens recommend increases of infusion rate at 15-20 min intervals. However, recent clinical studies agree that prolonged intervals of 30-40 or even 60 minutes are superior to shorter dosage intervals in terms of safety and efficacy.
A nurse is caring for a client who has bacterial vaginosis. Which of the following medication should the nurse expect to administer? A. Metronidazole B. Fluconazole C. Acyclovir
A. Metronidazole Treatment of bacterial vaginosis with oral metronidazole (Flagyl) is most effective, although vaginal preparations (e.g., metronidazole gel, clindamycin cream) are also used.
A nurse is caring for a client who is at 14 weeks of gestation. At which of the following locations should the nurse place the doppler device when assessing the fetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above the umbilicus D. Lateral at the Xiphoid Process
A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis Toward the end of the first trimester, before the uterus is an abdominal organ, the fetal heart tones (FHTs) can be heard with an ultrasound fetoscope or an ultrasound stethoscope (Fig. 8-8). To hear the FHTs, place the instrument in the midline just above the symphysis pubis and apply firm pressure. The woman and her family should be offered the opportunity to listen to the FHTs. The health status of the fetus is assessed at each visit for the remainder of the pregnancy.
A nurse is assessing a newborn who was born post-term. Which of the following findings should the nurse expect? A. Nails extending over tips of fingers B. Large deposits of subcutaneous fat C. Pale, translucent skin D. Thin covering of fine hair on shoulders and back
A. Nails extending over tips of fingers Overgrown nails, abundant scalp hair, visible creases on palms and soles of feet, minimal fat deposits etc.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first? A. Newborn who has nasal flaring B. Newborn who has subconjunctival hemorrhage of the left eye C. A newborn who has overlapping suture lines D. A newborn who has not rust-stained urine
A. Newborn who has nasal flaring Based on the ABC rule, respiratory distress needs more attention. Nasal flaring occurs when the nostrils widen while breathing. It is often a sign of trouble breathing. Nasal flaring may be an indication of breathing difficulty, or even respiratory distress in infants.
A nurse is assisting the provider administer a dinoprostone insert labor for a client. Which of the following actions should the nurse take?
A. Place the client in semi-fowler position for 1 hr after administration
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
A. Uterine Tenderness
A nurse is caring for a client at 34 week gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or abruptio placenta? a. Uterine tone b. Fetal heart rate c. Blood pressure d. Amount of bleeding
A. Uterine Tone The uterus will be relaxed, soft, and painless if the bleeding is cause by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain
A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM 12 hr. Available in dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)
ANS: 0.6 mL
A nurse is caring for newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the steps into the box on the placing them in the selected order of performance. Use all the steps.) A. Compress the bulb syringe B. Place the bulb syringe in the newborn's mouth C. Use the bulb syringe to suction the newborn's nose. D. Assess the newborn for reflex bradycardia
ANS: A, B, C, D Bulb must be compressed before inserting tip into mouth.
A nurse is caring for client who is in active labor. Following epidural placement, the nurse takes a maternal blood pressure of 98/58 mmHg and minimal FHR variability on the fetal monitor. Which of the following images indicates the action the nurse should take?
ANS: turn the client to her side before calling the health care provider (HCP)
A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following action should the nurse take? A. Decrease maintenance IV solution infusion rate. B Place the client in lateral position. C. Administer misoprostol 25 mcg vaginally D. Administer oxygen via face mask at 2 L/min
B Place the client in lateral position. By laying in the left lateral recumbent position, the uterus is kept off the maternal inferior vena cava and the right iliac artery. Increasing the rate of infusion of the maintenance IV solution is an appropriate action to take when late decelerations occur, not decreasing the rate. Oxygen should be administered at a rate of 8 to 10 L/min when late decelerations occur due to uterine hyperstimulation. Though it was not listed in the multiple choice discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.
A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work. Which of the following information should the nurse include in the teaching? A. "Thawed (defrosted) breast milk can be refrigerated for up to 72 hours." B. "Breast milk can be stored in a deep freezer for 12 months." C. "Breast milk can be stored at room temperature for up to 12 hours." D. "Thawed breast milk that is unused can be refrozen."
B. "Breast milk can be stored in a deep freezer for 12 months." Freshly expressed or pumped milk can be stored: At room temperature (77°F or colder) for up to 4 hours. In the refrigerator for up to 4 days. In the freezer for about 6 months is best; up to 12 months is acceptable.
A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply). A. "I will limit my time in the hot tub to 30 minutes after exercise." B. "I should consume three 8-ounce glasses of water after I exercise." C. "I will check my heart rate every 15 minutes during exercise sessions." D. "I should limit exercise sessions to 30 minutes when the weather is humid." E. "I should rest by lying on my side for 10 minutes following exercise."
B. "I should consume three 8-ounce glasses of water after I exercise." C. "I will check my heart rate every 15 minutes during exercise sessions." E. "I should rest by lying on my side for 10 minutes following exercise." Stay hydrated. Drink two or three 8-oz glasses of water after you exercise to replace the body fluids lost through perspiration. While exercising, drink water whenever you feel the need. Take your pulse every 10 to 15 minutes while you are exercising. If it is more than 140 beats/min, slow down until it returns to a maximum of 90 beats/min. Rest for 10 minutes after exercising, lying on your side. As the uterus grows, it puts pressure on a major vein in your abdomen, which carries blood to your heart. Lying on your side removes the pressure and promotes return circulation from your extremities and muscles to your heart, thereby increasing blood flow to your placenta and fetus.
A nurse is providing discharge teaching to a client following tubal ligation (occlusion). Which of the following statement by the client indicates an understanding of the teaching? A. "premenstrual tension will no longer be present." B. "Ovulation will remain the same." C. "Hormone replacements will be needed following this procedure." D. "My monthly menstrual period will be shorter."
B. "Ovulation will remain the same." Ovulation (egg release from the ovaries) will remain the same. Tubal ligation also known as having your tubes tied or tubal sterilization is a type of permanent birth control. During tubal ligation, the fallopian tubes are cut, tied or blocked to permanently prevent pregnancy. Tubal ligation prevents an egg from traveling from the ovaries through the fallopian tubes and blocks sperm from traveling up the fallopian tubes to the egg. The procedure doesn't affect your menstrual cycle it just prevents fertilization.
A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching? A. "This test will confirm fetal lung maturity". B. "This test will determine adequacy of placental perfusion". C. "This test will detect fetal infection". D. "This test will predict maternal readiness for labor".
B. "This test will determine adequacy of placental perfusion". The goal of a nonstress test is to provide useful information about your baby's oxygen supply by checking his or her heart rate and how it responds to your baby's movement. The test might indicate the need for further monitoring, testing or delivery. Normally, a baby's heart beats faster when he or she is active later in pregnancy. However, conditions such as fetal hypoxia when the baby doesn't get enough oxygen can disrupt this response.
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? A. "Your stomach will empty rapidly" B. "You should expect your uterus to double in size" C. "You should anticipate nasal stuffiness" D. "Your nipples will become lighter in color"
B. "You should expect your uterus to double in size" The uterus rises gradually to the level of the umbilicus at 22 to 24 weeks of gestation and nearly reaches the xiphoid process at term.
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plans to conduct? A. Group B strep culture B. 1-hr glucose tolerance test C. Rubella titer D. Blood type and Rh
B. 1-hr glucose tolerance test A glucose challenge test is usually conducted between 24 and 28 weeks of pregnancy. Abnormal glucose levels may indicate gestational diabetes.
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol? A. A client who has active genital herpes B. A client who has gestational diabetes mellitus C. A client who has a previous uterine incision D. A client who has placenta previa
B. A client who has gestational diabetes mellitus Induction of labor with misoprostol contraindicates with prior classic uterine incision, active genital herpes infection, placenta or vasa previa, & transverse fetal lie. And there is no study that shows there a contraindication to a client with gestational diabetes.
A nurse is caring for newborn who is 1 hr. old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.10 C (97F). Which of the following actions should the nurse take? A. Give the newborn a warm bath. B. Apply a cap to the newborn head. C. Reposition the newborn. D. Obtain an oxygen saturation level
B. Apply a cap to the newborn head. A cap may be worn to decrease heat loss from the infant's head.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Instruct the client to use effleurage B. Apply counter pressure to the client sacral. C. Assist the client with patterned-paced breathing. D. Teach the client the technique of biofeedback.
B. Apply counter pressure to the client sacral. Application of sacral counterpressure helps the woman cope with the sensations of internal pressure and pain in the lower back. It is especially helpful when back pain is caused by pressure of the occiput (back of the head) against spinal nerves, therefore counterpressure lifts the occiput off these nerves, thereby providing pain relief.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Dress the newborn in lightweight clothing. B. Avoid using lotion or ointment on the newborn skin. C. Keep the newborn supine throughout treatment D. Measure the newborn's temperature every 8hr
B. Avoid using lotion or ointment on the newborn skin. Frequent skin care is important, but do not use lotions, creams, balms, or ointments on uncovered skin. These products react with the phototherapy lights and cause burns.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? A. Place a snug dressing on the client's nipple when not breastfeeding. B. Ensure the newborn's mouth is wide open before latching to the breast. C. Encourage the client to limit the newborn's feeding to 10 min on each breast. D. Instruct the client to begin the feeding with the nipple that is most tender.
B. Ensure the newborn's mouth is wide open before latching to the breast. To decrease nipple discomfort, the mother has to make sure that the baby's mouth is open wide before latching him or her on to the breast.
A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations
B. Expiratory grunting Expiratory grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider.
A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include? A. Position the client on her hands and knees while in bed B. Flex the client's legs apart and raise her knees to her abdomen C. Apply gentle pressure on the client's fundus while she is lying supine D. Push the fetus's anterior shoulder under the symphysis pubis externally
B. Flex the client's legs apart and raise her knees to her abdomen The McRoberts maneuver includes helping the client flex her knees apart, which rotates the pubic bone anteriorly. This movement releases the anterior shoulder, but the nurse should not apply pressure directly to the anterior shoulder during this maneuver. This maneuver can be used for clients with or without epidural anesthesia
A nurse is teaching a client who is 28 weeks of gestation and not up to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth? A. Pneumococcal B. Hepatitis B C. Humanpapillomavirus D. Rubella
B. Hepatitis B Hepatitis B immunization is recommended at birth, 1 to 2 months, and between 6 to 18 months. It is injected intramuscularly soon after birth.
A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as having the lowest incidence of GDM? A. Asian B. Non-Hispanic White American C. Hispanic D. African American
B. Non-Hispanic White American GDM is more likely to occur among Hispanic, Native American, Asian, and African American women than Caucasians and is likely to recur in future pregnancies; the risk for development of overt diabetes in later life is also increased.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease? A. The mother is Rh positive, and the father is Rh negative. B. The mother is Rh negative, and the father is Rh positive. C. The mother and the father are both Rh positive. D. The mother and the father are both Rh negative.
B. The mother is Rh negative, and the father is Rh positive. Hemolytic Diseases in Newborns (HDN) most frequently occurs when a Rh-negative mother has a baby with a Rh-positive father. When the baby's Rh factor is positive, like the father's, problems can develop if the baby's red blood cells cross to the Rh-negative mother. This usually happens at delivery when the placenta detaches.
A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2 months of pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will count baby's kicks every other day." B. "I will alternate the arm use to check my blood pressure." C. "I will check my urine for protein daily." D. "I will consume 50 grams of protein daily."
C. "I will check my urine for protein daily." This urine will be tested to see if you are passing more than 300 mg of protein in a day. Any amount of protein in your urine over 300 mg in one day may indicate preeclampsia. However, the amount of protein doesn't define how severe the preeclampsia is or may get. To test your urine protein at home on a daily basis, use a simple test kit containing a urine testing strip that you dip into a fresh sample of your urine.
A nurse is teaching a client who is in labor 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 between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."
C. "I will feel the effects of the nitrous oxide almost immediately" The effects of nitrous oxide are felt within 1 minute of inhalation.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has diabetes mellitus and an HbA1c of 5.8% B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36%
C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L As a consequence of this physiological adaptation, normal pregnancy is associated with reduction in serum sodium of 3-6 mmol/L and reduction in serum osmolality of 10 mOsm/kg. Hyponatremia is diagnosed if serum sodium <135 mmol/L in non-pregnant individuals, but <130 mmol/L in pregnant women.
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider? A. A client who has a urinary output of 300 ml in 8 hr. B. A client who reports abdominal cramping during breastfeeding C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes. D. A client who reports lochia rubra requiring changing perineal pads every 3 hr.
C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes. Symptoms of magnesium sulfate toxicity are seen with the following maternal serum concentrations: loss of deep tendon reflexes (9.6-12 mg/dL) (> 7 mEq/L), respiratory depression (12-18 mg/dL) (> 10 mEq/L), and cardiac arrest (24-30mg/dL) (> 25mEq/L).
A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer? A. Metronidazole B. Penicillin C. Acyclovir D. Gentamicin
C. Acyclovir Acyclovir is used to treat infections caused by certain types of viruses. It treats cold sores around the mouth (caused by herpes simplex), shingles (caused by herpes zoster), and chickenpox. This medication is also used to treat outbreaks of genital herpes.
A nurse is caring for an infant who begins displaying manifestation of neonatal absentince syndromes (NAS). Which of the following action 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 handing the infant during the withdrawal phase
C. Avoid eye contact during feedings
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication? A. Hypnosis B. Polyuria C. Bilateral crackles D. Hyperglycemia
C. Bilateral crackles Since opioids can sometimes cause slow breathing or other breathing problems, bilateral crackles are one of the adverse effects of epidural block with opioid analgesia.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include? A. Tinnitus B. Urinary Frequency C. Breast Tenderness D. Chills
C. Breast Tenderness The adverse effects of clomiphene citrate are stomach upset, bloating, abdominal/pelvic fullness, flushing ("hot flashes"), breast tenderness, headache, or dizziness may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Apply a thin layer of lotion to the newborn skin every 8 hrs. B. Give the newborn 1 oz of glucose water every 4 hrs. C. Ensure the newborn eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy
C. Ensure the newborn eyes are closed beneath the shield. Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.
A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery Cracked skin
C. Extended extremities An infant born at 32 weeks gestation has poorly developed muscle tone and is unable to maintain the flexed position seen in infants born at full term.
A nurse is assessing a newborn following forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method? A. Hypoglycemia B. Polycythemia C. Facial Palsy D. Bronchopulmonary dysplasia
C. Facial Palsy Difficult delivery, with or without the use of an instrument called forceps, may lead to facial palsy. Facial paralysis 15 minutes after forceps birth or absence of movement on affected side is especially noticeable when infant cries.
A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. Nausea and Vomiting B. Tachycardia C. Hypotension D. Respiratory depression
C. Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.
A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should charge nurses include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to main body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability
C. Impaired Placental perfusion Maternal hypotension can occur in 10% to 30% of women who received epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factor may increase the risk of pathologic hyperbillrubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia
C. Infection Blood group incompatibilities, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Provide a stimulating environment B. Monitor blood glucose level every hr. C. Initiate seizure precautions. D. Place the infants on his back with legs extended.
C. Initiate seizure precautions. Initiate seizure precautions since signs of withdrawal in neonates are Irritability • Seizures • Hyperactivity • High-pitched cry • Tremors • Exaggerated Moro reflex • Hypertonicity of muscles.
A nurse is caring for a client who is 4 hrs. postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Administer indomethacin orally B. Insert a second IV using a 22-gauge IV catheter, C. Insert an indwelling urinary catheter. D. Administer oxygen at 2 L/min via nasal cannula.
C. Insert an indwelling urinary catheter. Insert an indwelling urinary catheter to monitor perfusion of kidneys. Provide additional or maintain existing IV infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume (woman should have two patent IV lines; insert second IV infusion using 16- to 18-gauge IV catheter). Give oxygen by nonrebreather face mask or nasal prongs at 8 to 10 L/min.
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 promote rotation of the fetal head? A. Apply counterpressure to the client's back B. Place heat on the client's lower back C. Instruct the client to squat during contraction D. Encourage the client to ambulate in the hall
C. Instruct the client to squat during contractions Measure to encourage rotation of the fetal head to a more anterior position include squatting during contraction, getting on hand and knees during contractions, and lying on the same side as the fetal spine.
A nurse is caring for a client who just had spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and 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 to 10 L/min of oxygen via a nonrebreather face mask
C. Manually apply upward pressure intravaginally on the presenting part
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for infection. A. Meconium-stained fluid B. placenta previa C. Midline episiotomy D. Gestational hypertension
C. Midline episiotomy Midline episiotomy puts the client in risk for infection.
A nurse is developing a plan of care who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse include in the plan? A. Monitor the client's blood pressure every hour B. Restrict the total hourly intake to 200 mL C. Monitor the FHR continuously.
C. Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizure in clients who have preeclampsia, is a high-alert medication that requires close monitoring . The FHR and uterine contraction should be monitored continuously while the client is receiving magnesium sulfate.
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. Motting The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress.
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.) A. Administer nitric oxide inhalation therapy to the newborn B. Insert an orogastric decompression tube with low wall suction. C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.
C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. E. coli can cause a severe complication that occurs most commonly in young children (age 5 and younger) called hemolytic uremic syndrome. This condition destroys platelets and red blood cells and leads to kidney failure.
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 serosanguineous drainage is noted in the newborn's diaper. B. The newborn's circumcision site is covered with yellow exudate. C. The newborn has urinated once since the circumcision. D. The newborn fusses during each diaper change.
C. The newborn has urinated once since the circumcision A newborn should void 2 to 6 times a day the first 24 to 48 hours after birth and then 5 to 8 times per day starting on the third day. Therefore, the nurse should report 1 void in 24 hours following circumcision to the provider.
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider? A. Blood pressure 148/94 mmHg B. Respiratory rate 14 breath/min C. Urinary output 20 mL/hr. D. 2+ deep tendon reflexes
C. Urinary output 20 mL/hr. The client's urine output should be at least 25 to 30 mL/hr. to promote adequate excretion of magnesium. The nurse should stop the infusion & notify the provider.
A nurse in a provider's office is caring for a 20-year old client who is at 12 weeks gestation and requests an amniocentesis to determine the sex of her fetus. Which of the following responses should the nurse make? A."You cannot have an amniocentesis until you are at least 35 years of age.". B."We can schedule the procedure for later today if you'd like.". C." This procedure determines if your baby has genetic or congenital disorders.". D,"Your provider will schedule a chorionic villus sampling to determine the sex of your baby.".
C." This procedure determines if your baby has genetic or congenital disorders."
A nurse is proving teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client indicated an understanding of the teaching?
D. "This medication could cause me to experience heart palpitations"
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? A. "your contraction will become more intense when walking" B. "you will have dilation and effacement of the cervix" C. "you will have bloody show" D. "your contraction will become temporally regular"
D. "your contraction will become temporally regular" During false labor contraction occur irregularly or become regular only temporarily. Often stop with walking or position change.
16. A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. 1⁄2 cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli
D. 1 cup cooked broccoli 1⁄2 cup cubed avocado contains 9 mg of calcium. 1 large banana contains 7 mg of calcium. 1 medium potato 26 mg of calcium. 1 cup cooked broccoli contains 180 mg of calcium.
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
D. A client who has felt quickening for the first time
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit? A. A client who has an ultrasound that confirms a molar pregnancy B. A client who has a crown-rump length of 7 weeks gestation C. A client who has a positive urine pregnancy test 1 week after missed menses D. A client who has felt quickening for the first time.
D. A client who has felt quickening for the first time. In pregnancy terms, quickening is the moment in pregnancy when the pregnant woman starts to feel or perceive fetal movements in the uterus.
A nurse is preparing to administer routine medications to newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erythromycin eye ointment within 12 hours C. Administer erythromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh
D. Administer vitamin K in the newborn's thigh The nurse should administer vitamin K in the vastus lateralis muscle in the newborn;s thigh.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care? A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation. B. Use a fetal scalp electrode during labor and delivery. C. Administer a pneumococcal immunization to the newborn within 4 hrs. following birth. D. Bathe the newborn before initiating skin-to-skin contact
D. Bathe the newborn before initiating skin-to-skin contact
A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect? A. Bulging Fontanels B. Nasal Flaring C. Length from head to heel of 40 cm (15.7 in) D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
D. Chest circumference 2 cm (0.8 in) smaller than the head circumference Measure at nipple line 2-3 cm (0.8-1.2 in) less than head circumference; average 30-33 cm (11.8-13 in) ≤ 30 cm.
A nurse in a woman's health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client's risk for developing pelvic inflammatory disease (PID)? A. Recurrent Cystitis B. Frequent Alcohol Use C. Use of Oral Contraceptives D. Chlamydia Infection
D. Chlamydia Infection Pelvic inflammatory disease is an infection of a woman's reproductive organs. It is a complication often caused by some STDs, like chlamydia and gonorrhea. Other infections that are not sexually transmitted can also cause PID.
A nurse is assessing a client who is at 34 weeks gestation and has a mild placental abruption. Which finding should the nurse expect? A. Increased platelet count B. Fetal distress C. Decreased urinary output D. Dark red vaginal bleeding
D. Dark red vaginal bleeding The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal bleeding.
A nurse is receiving laboratory results for a term newborn who is 24 hrs. old. Which of the following results require intervention by the nurse? A. WBC count 10,000/mm3 B. Platelets 180,000/mm3 C. Hemoglobin 20g/dL D. Glucose 20 mg/dL
D. Glucose 20 mg/dL But at birth, it's common for a newborn to have a blood glucose level as low as 30 mg per dl, which will gradually increase to 54 to 72 mg/dl. According to guidelines from the American Academy of Pediatrics, the generally accepted blood glucose level for treating newborn hypoglycemia is 47 mg/dl.
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? A. Hyperemesis B. Proteinuria C. Hypoxia D. Hemorrhage
D. Hemorrhage That is why ultrasound scanning has reduced risks previously associated with amniocentesis such as fetomaternal hemorrhage from a pierced placenta.
A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect? A. Thick, White Vaginal Discharge B. Urinary Frequency C. Vulva Lesions D. Malodorous Discharge
D. Malodorous Discharge Although trichomoniasis may be asymptomatic, women commonly experience characteristically yellowish-to-greenish, frothy, mucopurulent, copious, malodorous discharge. Inflammation of the vulva, vagina, or both may be present; and the woman may complain of irritation and pruritus. Dysuria and dyspareunia are often present.
A nurse on a labor and delivery unit is reviewing infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures? A. Assisting a mother with breastfeeding B. Performing a newborn's initial bath C. Administering the measles, mumps, rubella vaccine D. Performing umbilical cord care
D. Performing umbilical cord care Wear gloves when a reasonably anticipated possibility exists that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) might occur. Gloves should be worn during infant eye prophylaxis, care of the umbilical cord, circumcision site, parenteral procedures, diaper changes, contact with colostrum, and postpartum assessments. Wear gloves with fit and durability appropriate to the task.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? A. Urine protein concentration 200 mg/24 hr. B. Creatinine 0.8 mg/ dL C. Hemoglobin 14.8 g/ dL D. Platelet Count 60,000/ mm3
D. Platelet Count 60,000/ mm3 Platelets < 100,000/mm3 (60,000/mm3) is below the expected reference range, which can indicate DIC. The nurse should report this result to the provider. In a 24-hour specimen proteinuria is defined as a concentration at or > 300 mg/24 hours.
A nurse is caring for a newborn who is 6 hrs. old and has a bedside glucometer reading of 65 mg/dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take? A. Obtain a blood sample for a serum glucose level B. Feed the newborn immediately C. Administer 50 mL of dextrose solution IV D. Reassess the blood glucose level prior to the next feeding.
D. Reassess the blood glucose level prior to the next feeding. When babies are just 1 hour to 2 hours old, the normal level is just under 2 mmol/L (36 mg/dL), but it will rise to adult levels (over 3 mmol/L or 54 mg/dL) within two to three days. In babies who need treatment for low blood glucose or are at risk for low blood glucose, a level over 2.5 mmol/L (45 mg/dL) is preferred.
A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect? A. Minimal arm recoil B. Popliteal angle of less than 90 C. Creases over the entire sole D. Sparse (thin) lanugo
D. Sparse (thin) lanugo Fine hair (lanugo) covering much of the body is expected with preterm newborn.
A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene? A. Molding B. Vernix Caseosa C. Acrocyanosis D. Sternal retractions
D. Sternal retractions Sternal retraction is a common clinical sign of respiratory distress in premature infants. Frontal chest radiographs show increased, ill-defined central radiolucency over the lower chest which correlates well with a curvilinear indentation seen on lateral views.
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? A. The client expels the placenta. B. The client experiences gradual dilation of the cervix C. The client begins to have regular contractions. D. The client delivers the newborn.
D. The client delivers the newborn. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus.
A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? A. Weak cry B. Absent Moro reflex C. Constipation D. Tremors
D. Tremors Newborns who have neonatal abstinence syndrome can have tremors, tachypnea, nasal flaring, apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers. Incorrect Answer: A. Newborns who have neonatal abstinence syndrome exhibit a shrill cry. B. Newborns who have neonatal abstinence syndrome exhibit an exaggerated reflex. C. Newborns who have neonatal abstinence syndrome can exhibit diarrhea
A nurse is caring for a client who has hyperermesis gravidarum. Which of the following laboratory tests should the nurse anticipate? A. complete blood count B. Liver enzymes C. Bilirubin Level D. Urine ketones
D. Urine Ketones When using the urgent vs nonurgen approach to client care, the nurse should determine that the priority laboratory test to check is urine ketones. Excessive ketones in the urine indicate the body is not using carbohydrates from food as fuel and is inadequately trying to break down fat.
A nurse is assessing a client who is recieving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? A. Respiratory rate 14/min B. Temperature 37.8 C (100 F) C. dizziness upon rising D. Urine output 20 mL/hr
D. Urine output 20mL/hr Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 ml/hr. The nurse should report this finding to the provider.
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse report to the provider?
D. Urine output less than 20
A nurse is caring for a newborn who is 24 hrs. old. Which of the following laboratory findings should the nurse report to the provider? A. Hgb 20 g/dL B. Bilirubin 2 mg/dL C. Platelets 200,000/mm3 D. WBC count 32,000/mm3
D. WBC count 32,000/mm3 An abnormal number of WBCs often indicates that the newborn baby's body is fighting some sort of infection. Results of the CBC can be obtained quite quickly. Blood culture: The blood culture will determine if any bacteria can be grown in the blood.
A nurse is performing an initial assessment of a newborn who was delivered with nuchal cord. which of the following clinical finding should the nurse expect?
Facial Petechiae
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following finding should the nurse report to the provider?
Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be preformed.
