Maternal Newborn ATI 2019 B
A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?
Jitteriness
A nurse is teaching a client who has pre gestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I will continue taking my insulin if I experience nausea and vomiting."
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
"I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat to taste to avoid nausea.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?
"I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
"Staff members who take care of your baby will be wearing a photo identification badge."
A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?
"This medication stimulates fetal lung maturity."
A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make?
"This procedure should have no effect on your sexual performance or adequacy."
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
"You should take the medication within 72 hours following unprotected sexual intercourse."
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available is 250 mg tablets. How many tablets should the nurse administer?
4 tablets
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
? Eyes tightly closed, mouth open in a squarish shape, eyebrows lowered and drawn together
A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?
? Hgb less than 11 mg/dL Hct less than 33.0% Glucose 40 to 60 mg/dL
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
A client who is at 34 weeks of gestation and reports epigastric pain Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions?
Administer terbutaline The nurse should administer terbutaline to stop contractions because the lab results indicate that the fetus's lungs are not mature enough for delivery.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Access emergency medications from cart
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
Apple cabbage leaves to the breasts
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?
Apply internal upward pressure to the presenting part using two gloved fingers
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8cm and reports back pain. Which of the following actions should the nurse take?
Apply sacral counterpressure This relieves back labor pain related to fetal posterior position
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Assist the client to empty her bladder.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
Biophysical profile (BPP)
A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medications. For which of the following findings should the nurse instruct the client to notify the provider?
Breakthrough bleeding
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
Cover the newborn's eyes while under the phototherapy light.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purport (ITP). Which of the following findings should the nurse expect?
Decreased platelet count
Nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?
Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new mother moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?
Emotional lability
A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyper pigmentation on her forehead. Which of the following actions should the nurse take?
Explain to the client that this is a normal occurrence.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for administration of the medication?
Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Have calcium gluconate readily available.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
Headache that is unrelieved by analgesia
A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
I will need this medicine if I have an amniocentesis rhogam is recommended following an amniocentesis because of the potential of fetal RBC's entering the maternal circulation
A nurse is planning care for a client who is to undergo a non stress test. Which of the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected
A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?
Iron supplements
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart times (FHT)?
Just above the symphysis pubis
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
Leakage of fluid from the vagina
A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apple the ultrasound transducer to assess the point of maximum intensity of the fetal heart?
Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
Massage the client's fundus
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Monitor the client's blood pressure every 5 minutes following the first dose of anesthetic solution
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Oligohydramnios
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
Palpate client fundus to identify the fetal part. Determine the location of the fetus back Palpate for the fetal part presenting at the inlet Identify the attitude of the head
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?
Platelet count 120,000/mm3
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
Platelets 50,000/mm3
A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?
September 3rd
A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spinal bifida occult?
Small pump on baby's back Dimpling in the lumbosacral area (occulta)
A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?
Stop suctioning when the newborn's cry sounds clear
A nurse is assessing a client who is at 30 weeks of gestations during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
Swelling of the face
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Temperature
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Transition
A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider?
Unilateral breast pain Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Verify the newborn's identification
A nurse is assessing the newborn of a client who took a selective serotonin reuptake (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Vomiting
A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?
"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should teach the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.
A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?
"Check the temp of your baby's bath water with you hand."
A nurse in a prenatal clinic for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
"You can miss your period for several other reasons. Describe your typical menstrual cycle."
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?
"You should leave the diaphragm in place for at least 6 hours after intercourse."
A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take?
? Perform a vaginal exam to determine cervical dilation every 2hr. Fetal monitoring for fetal well-being assessment
A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?
? RBC count 5.8 million/mm3 Bilirubin - 24hr 2 to 6 mg/dL 48hr 6 to 7 mg/dL 3 to 5 days 4 to 6 mg/dL
A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?
? Rear-facing car seat till the age of 2yrs Use a car seat with a fit-point harness
A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching?
? S A A
A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?
? Substernal chest retractions while sleeping
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives?
Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptive . Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use or oral contraceptives.
