Maternal Newborn ATI Practice 2019 A
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.) A. HR 154/min B. Axillary temp 36 C. RR 58/min D. Length 43cm (16.9in) E. Weight 2,600g (5lb 12 oz)
A, C, E
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A. "I can administer oxytocin 4 hours after the insertion of the medication." B. "You will need a full bladder prior to the insertion of the medication." C. "Remain in a side-lying position for 15 minutes after the medication is inserted." D. "An antacid will be given 20 minutes prior to the insertion of the medication."
A. "I can administer oxytocin 4 hours after the insertion of the medication."
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? A. BUN 25 B. Creatinine 0.8 C. Urine output of 280mL within * hr D. Urine negative for ketones
A. BUN 25
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? A. Reports increased urinary output B. Diaphoresis C. Reports blurred vision D. Shallow respirations
A. Reports increased urinary output
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? A. Substernal retractions B. Acrocyanosis C. Overlapping suture lines D. Head circumference 33 cm
A. Substernal retractions
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? A. Verify that the parent's identification band matches the newborn's identification band B. Scan the newborn's identification band to verify their identity C. Check the newborn's security tag number to ensure it matches the newborn's medical record D. Match the newborn's date and time of birth to the information in the parent's medical record
A. Verify that the parent's identification band matches the newborn's identification band
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? A. Determine progression of dilation and effacement. B. Perform Leopol maneuvers. C. Complete a sterile speculum exam D. Prepare a Nitrazine paper test.
B. Perform Leopol maneuvers.
A nurse is caring for a prenatal client who has parovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication B. Schedule an ultrasound examination C. Administer Haemophilus influenzae type b vaccine D. Schedule an indirect Coombs' test
B. Schedule an ultrasound examination
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? A. Lochia serosa vaginal dranage B. Vaginal pressure C. Intermittent vaginal pain D. Yellow exudate vaginal drainage
B. Vaginal pressure
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? A. "Obtain an informed consent prior to obtaining the specimen." B. "Collect at least 1 milliliter of urine for the test." C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." D. "Premature newborns may have false negative tests due to immature development of liver enzymes."
C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen."
A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? A. "You can resume sexual activity in 1 week." B. "You won't need to do Kegal exercises since you need a cesarean." C. "You can still become pregnant if you are breastfeeding." D. "You are safe to start adding sit-ups to you exercise routine 2 weeks."
C. "You can still become pregnant if you are breastfeeding."
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? A. Give the client orange juice. B. Elevate the client's legs. C. Have the client change position. D. Establish IV access
C. Have the client change position.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? A. Acrocyanosis B. Transient strabismus C. Jaundice D. Caput succedaneum
C. Jaundice
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a 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 D. Administer protamine sulfate for manifestations of toxicity
C. Monitor the FHR continuously
A nurse is assisting a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? A. Fentanyl B. Butophanol C. Naloxone D. Meperidine
C. Naloxone
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? A. Allow the sibling to hold the newborn during a bath B. Make sure the sibling kisses the newborn each night C. Obtain a gift from the newborn to present to the sibling. D. Switch the sibling's room with the nursery
C. Obtain a gift from the newborn to present to the sibling.
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? A. Bruising over the buttocks B. Hard nodules on the roof of the mouth C. Petechiae over the head D. Bilateral periauricular papillomas
C. Petechiae over the head
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? A. Excessive bleeding B. Oligohydramnios C. Premature rupture of membranes D. Proteinuria
C. Premature rupture of membranes
A nurse is caring for a client who is at 30 weeks of gestation and has prescription of magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? A. Client reports nausea B. Urinary output of 40ml/hr C. RR of 10 D. Client reports feeling flushed
C. RR of 10
A nurse is demonstrating to a pt. how to bathe her newborn. In which order should the nurse perform the following actions? A. Wash the newborns neck by lifting the newborn's chin B. Wash the newborn's legs and feet C. Clean the newborn's diaper area D. Wipe the newborn's eyes from the inner canthus outward E. Cleanse the skin around the newborn's umbilical cord stump
D, A, E, B, C
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should increase my protein intake to 60 grams each day." B. "I should drink 2 liters of water each day." C. "I should increase my overall daily caloric intake by 300 calories." D. "I should take 600 micrograms of folic acid each day."
D. "I should take 600 micrograms of folic acid each day."
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? A. "The test should take 10-15 minutes to complete." B. "You will lay in a supine position throughout the test." C. "You should not eat or drink for 2 hours before the test." D. "You should press the handheld button when you feel your baby move."
D. "You should press the handheld button when you feel your baby move."
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A. A newborn who is 26 hr old and has erythema toxicum on his face B. A newborn who is 32 hr old and has not passed a meconium stool C. A newborn who is 12 hr old and has pink-tinged urine D. A newborn who is 18 hr old and has an axillary temperature of 37.7 degrees C
D. A newborn who is 18 hr old and has an axillary temperature of 37.7 degrees C
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? A. Deep tendon reflexes 4+ B. Fundal height 14cm C. Urine protein 2+ D. FHR 152/min
D. FHR 152/min
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's is the priority following the procedure? A. Check the client's temperature B. Observe for uterine contractions. C. Administer Rhogam D. Monitor FHR
D. Monitor FHR
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A. Apply a cool pack fo 10 minutes to the heel prior to the puncture. B. Request a prescription for IM analgesic C. Use a manual lance blade to pierce the skin D. Place the newborn skin to skin on the mother's chest.
D. Place the newborn skin to skin on the mother's chest.
A nurse is a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the follwoing findings should the nurse identify as a risk factor for the development of preeclampsia? A. Singleton pregnancy B. BMI of 20 C. Maternal age of 32 D. Pregestational diabetes mellitus
D. Pregestational diabetes mellitus
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? A. Administer penicillin G 2.4 million units IM to the client B. Instruct the client to schedule an annual pelvic examination. C. Tell the client she will start medication for HIV immediately after delivery D. Report the client's condition to the local health department
D. Report the client's condition to the local health department
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? A. Biophysical profile B. Amniocentesis C. Cordocentesis D. Kleihauer-Betke test
A. Biophysical profile
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Report of visual disturbances B. Report of tingling of the fingers C. Report of urinary frequency D. Report of leg cramps
A. Report of visual disturbances
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? A. Hypertonia B. Increased feeding C. Hyperthermia D. Respiratory distress
Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations include abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
A nurse in a prenatal clinic is assessing a group of pts. Which of the following pts. should the nurse request the provider see first? A. A client who is at 11 weeks of gestation and reports abdominal cramping. B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
A. A client who is at 11 weeks of gestation and reports abdominal cramping.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? A. Abruptio placenta B. Placenta previa C. Preeclampsia D. Maternal bradycardia
A. Abruptio placenta
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? A. Calcium gluconate B. Hydralazine C. Medroxyprogesterone acetate D. Methylergonovine
A. Calcium gluconate
A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? A. Cold cabbage leaves B. Purified lanolin cream C. A snug-fitting support bra D. Breast shells
A. Cold cabbage leaves
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? A. Depression B. Polyuria C. Hypotension D. Urticaria
A. Depression
A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? A. Hemoglobin 10g/L B. WBC 10,000 C. Platelets 250,000 D. Fasting blood glucose 90
A. Hemoglobin 10g/L
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? A. Hypertension B. Hypothermia C. Constipation D. Muscle weakness
A. Hypertension
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? A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. B. Wrap the visible cord tightly with sterile, dry gauze. C. Apply oxygen to the client at 2L/min via nasal cannula. D. Place the client in the lithotomy position and apply fundal pressure.
A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.
The nurse is caring for a client who is at 24 weeks of gestation and has suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin (L/S) ratio D. Maternal Alpha-fetoprotein (AFP)
A. Kleihauer-Betke test
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? A. Late decelerations B. Moderate variability in the FHR C. Cessation of uterine dilation D. Prolonged active phase of labor.
A. Late decelerations
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? A. Lays the newborn across her lap and gently sways B. Places the newborn in the crib in a prone position C. Offers the newborn a pacifier dipped in formula D. Prepares a bottle of formula mixed with rice cereal.
A. Lays the newborn across her lap and gently sways
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? A. Minimal arm recoil B. Popliteal angle of 90 degrees C. Creases over the entire foot sole D. Raised areolas with 3-4 mm buds
A. Minimal arm recoil
A nurse is creating a plan of care for a pt. who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? A. Protect the client's head and feet from cold air B. Bathe the client within 12 hr following birth C. Ambulate the client within 24 hr following birth D. Offer the client a glass of cold milk with their first meal
A. Protect the client's head and feet from cold air
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Yellow sclera B. Acrocyanosis C. Posterior fontanel larger than the anterior fontanel D. Positive Babinski reflex E. Two umbilical arteries visible
B, D, E
A nurse is providing teaching to a client about physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? A. "I will not gain more than 15-20 lbs during my pregnancy." B. "I will likely need to use alternative positions for sexual intercourse." C. "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." D. "I'm glad I have a light complexion and will not get any stretch marks."
B. "I will likely need to use alternative positions for sexual intercourse."
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? A. Administer aspirin for pain B. Maintain the client on bed rest C. Massage the affect leg every 12 hr D. Apply cold compresses to the affected calf
B. Maintain the client on bed rest
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? A. Check the client's capillary refill. B. Massage the client's fundus. C. Insert an indwelling urinary catheter for the client. D. Prepare the client for a blood transfusion.
B. Massage the client's fundus.
A nurse is an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Fundal height 34cm B. Report of decreased fetal movement C. Report of occasional ankle swelling D. BP 110/80
B. Report of decreased fetal movement
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? A. To estimate the fetal weight B. To locate a pocket of fluid C. To determine multiparity D. To prescreen for fetal anomalies
B. To locate a pocket of fluid .
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? A. "My sister will be able to carry my baby form the nursery to my room when she arrives." B. "The nurse will match my wrist band to my baby's crib card when they bring him to me." C. "The person who comes to take my baby's pictures will be wearing a photo identification badge." D. "My baby doesn't need to wear the electronic security bracelet when he's in my room."
C. "The person who comes to take my baby's pictures will be wearing a photo identification badge."
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? A. Decreased uterine contractions B. An increase in the client's hemoglobin levels C. A reduction in respiratory distress in the newborn D. Increased production of antibodies in the newborn
C. A reduction in respiratory distress in the newborn
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? A. Monitor FHR B. Assess uterine activity C. Administer oxygen via a nonrebreather mask D. Start a bolus of IV fluids
C. Administer oxygen via a nonrebreather mask
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? A. Feed the newborn 1 oz of water every 4 hr B. Apply lotion to the newborn's skin three times per day. C. Remove all clothing from the newborn except the diaper. D. Discontinue therapy if the newborn develops a rash.
C. Remove all clothing from the newborn except the diaper.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? A. BP 136/88 B. Report of insomnia C. Weight gain of 2.2 kg D. Report of Braxton Hicks contractions
C. Weight gain of 2.2 kg
A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? A. Perform Nitrazine testing B. Assess the fluid C. Check cervical dilation D. Begin FHR monitoring
D. Begin FHR monitoring
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? A. 2+ deep tendon reflexes B. Proteinurua of 200 mg in a 24 hours specimen C. Polyuria D. Blurred vision
D. Blurred vision
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20g magnesium sulfate in 500 ml of dextrose 5% in water. The nurse should set the IV infusion pump to administer how many ml/hr?
50
