maternal ATI
A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. Nursing action? A) Prepare client for ultrasound B) Prepare client for emergency cesarean C) prepare equipment needed for newborn resuscitation D) Perform endotracheal suctioning as soon as the fetal head is delivered.
C) Prepare equipment needed for newborn resuscitation.
a nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider? A) deep tendon reflexes 2+ B) BP 150/96 mm Hg C) urinary output of 20 mL/hr D) resps 16/min
C) urinary output 20 mL/hr This can indicate inadequate renal perfusion, increasing the risk of mag sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia
A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching? A) The fibroid will shrink during the pregnancy B) The fibroid can increase the risk for postpartum hemorrhage C) You will receive an injection of medroxyprogesterone acetate to shrink the fibroid D) You will have to undergo a cesarean birth because of the fibroid
"The fibroid can increase the risk for postpartum hemorrhage" Risk due to the increase in blood supply to the uterus, which supports the fibroid
a nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate? A) "you should drink one ounce of mineral oil every morning" B)"you should walk for at least 30 minutes every day" C) "you should eat at least 3 ounces of red meat per day" D) "you should stop taking your prenatal vitamin"
"you should walk for at least 30 minutes every day" Rationale: encourage the client to participate in moderate physical activity which increases intestinal peristalsis.
a nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which pf the following findings should the nurse identify as the priority? A) 480 mL urine output in 24 hours B) Blood pressure 144/92 mm Hg C) +2 edema of the feet D) 1+ protein in the urine
A) 480 mL urine output in 24 hours Rationale: when using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL in 24 hrs because the minimum acceptable urine output in an adult client is 20 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention.
A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hours. What would the nurse do? A) auscultate for the FHR B) Have the client drink orange juice C) Reassure the client that a term fetus is less active D) Palpate the uterus for fetal movement
A) Auscultate for a fetal heart rate Rationale: Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the FHR using a doppler device or an external fetal monitor. PRIORITY
a nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A) Betamethasone B) Misoprostol C) Methylergonovine D) Poractant alfa
A) Betamethasone Rationale: Administer IM (glucocorticoid) to stimulate fetal lung maturity and thereby prevent respiratory depression
A nurse is caring for a client who is at 39 weeks gestation and is in active phase of labor. The nurse observes late decelerations in the FHR. Cause of late decelerations? A) Uteroplacental insufficiency B) Fetal head compression C) Fetal ventricular septal defect D) Umbilical cord compression
A) Uteroplacental insufficiency Rationale: A late deceleration in the FHR is Non reassuring resulting from fetal hypoxemia due to insufficient placental perfusion. REPO, O2, IVF
a nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A) Perform a vaginal examination B) Perform continuous external fetal monitoring C) Insert a large-bore IV catheter D) obtain a blood sample for laboratory testing
A) perform a vaginal examination when a client has placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.
a nurse is teaching a client who is at 12 weeks of gestation about manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching? A) swelling of the face B) urinary frequency C) white vaginal discharge D) intermittent nausea
A) swelling of the face Rationale: can indicate a hypertensive disorder or preeclampsia
a nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A) use vibroacoustic stimulation on the clients abdomen for 3 seconds B) Report the nonreactive test result to the provider immediately C) request a prescription for an internal fetal scalp electrode D) auscultate the FHR with a doppler transducer
A) use vibroacoustic stimulation on the client's abdomen for 3 seconds Rationale: the nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continues IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A) elevated BP B) Feeling of warmth C) hyperactivity D) generalized pruritus
B) Feeling of warmth Rationale: the nurse should tell the client to expect the feeling of warmth all over her body while the mag is infusing.
A nurse is reviewing lab results for the client who is at 37 weeks gestation. Client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type O negative. Nursing Actions? A) Administer the RhoGAM IG B) Request a prescription for an antibiotic until delivery C) Instruct the client to obtain a rubella vax after delivery D) inform client she needs a c-section
B) Instruct the client to obtain a rubella immunization after delivery. Rationale: the client is not immune to rubella and should receive this immunization after delivery.
A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A) Perform a vaginal examination to determine cervical dilation B) Obtain blood samples for baseline laboratory values C) Place a spiral electrode on the fetal presenting part D) Prepare the client for a transvaginal ultrasound
B) Obtain blood samples for baseline laboratory values. Rationale: the nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed. Instructions the nurse should include? A) Stand under a hot shower with your breasts exposed B) Place ice packs on your breasts C) wear a loose fitting comfortable bra D) Limit fluid intake to 1 L per day
B) Place ice packs on your breasts. Rationale: use a 15 minute on 45 min off schedule to decrease swelling of the breast tissue as the body produces milk.
A nurse is caring for a client who has oligohydramnios. What anomalies should the nurse expect? A) Atrial septal defect B) Renal agenesis C) Spina bifida D) hydrocephalus
B) Renal agenesis Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys cause this
A nurse is assessing a client who is 37 weeks gestation and has suspected pelvic fracture due to blunt abdominal trauma. What finding is expected? A) Bradycardia B) Uterine contractions C) Seizures D) bradypnea
B) Uterine contractions
a nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A) hypothermia B) dark brown vaginal discharge C) decreased urinary output D) fetal heart tones
B) dark brown vaginal discharge MOLAR pregnancy benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters
A nurse is teaching a client who is at 13 weeks gestation about the treatment of incompetent cervix with cervical cerclage. Statement understood? A) "I am sad I can't get pregnant again" B) "I can resume sex when I am ready" C) "I should go to the hospital if I think I may be in labor" D) "I should expect bright red bleeding when the cerclage is in place"
C) "I should go to the hospital if I think I may be in labor" Rationale: cervical cerclage prevent premature opening of the cervix during pregnancy. Immediately go to a facility if any manifestations of labor while cerclage is in place.
A nurse is assessing a 12 hour old newborn and notes a RR of 44/min shallow respirations and periods of apnea lasting up to 10 minutes. Which of the following actions should the nurse take?
C) Continue routine monitoring Rationale: he is adapting to extrauterine life
A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 minutes which last 100 to 110 seconds and that the fetal heart rate is reassuring. Which of the following actions should the nurse take? B) Administer oxygen via nonrebreather mask C) Decrease the dose of oxytocin by half. D) Administer terbutaline 0.35 mg subcutaneously
C) Decrease the dose of oxytocin by half Rationale:
A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to PCP. What should be in the teaching? A) mild constipation B) Nasal congestion C) Vaginal bleeding D) 10 fetal movements per hour
C) vaginal bleeding. Rationale: can be an abnormal finding indicating: placental abruption, placenta previa, or preterm labor.
A nurse is teaching a client who is at 12 weeks of gestation and has HIV. Which of the following statements should the nurse include in the teaching? A) "Breastfeed your newborn to provide passive immunity." B) "Abstain from sexual intercourse throughout the pregnancy." C) "You will be in isolation after delivery." D) "You should continue to take zidovudine throughout the pregnancy."
D) "You should continue to take zidovudine throughout the pregnancy." Rationale: The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.
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. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy?
D) A urine test for the presence of human chorionic gonadotropin Rationale: Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone an estrogen. This is the basis for pregnancy testing
A nurse is assessing a client who is at 34 weeks gestation and has mild placental abruption. What would the nurse expect? A) Increased platelet count B) Fetal distress C) decreased urinary output D) dark red vaginal bleeding
D) Dark red vaginal bleeding. MINIMAL
A nurse is reviewing the medical record of a client who is 39 weeks of gestation and has polyhydramnios. Which of the findings would the nurse expect? A) Fundal height of 34 cm B) Total pregnancy weight gain of 3.6 kg C) Gestational hypertension D) Fetal gastrointestinal anomaly
D) Fetal gastrointestinal anomaly Rationale: Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios
A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take? A) instruct the client to pant during contractions B) position the client supine with legs elevated C) encourage the client to soak in a warm bath D) Apply pressure to the client's sacral area during contractions
D) apply pressure to the client's sacral area during contractions Rationale: Counter pressure to the sacral area with a palm or a firm object. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain.
Umbilical cord compression
cause of variable decelerations