OB ATI PROCTORED EXAM STUDY GUIDE
A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? a. "Your risk of pregnancy is greatest on days 21 to 28 of your cycle." b. "You should take your temperature before getting up for the day." c. "You should abstain from intercourse when your temperature is above 100℉." d. "Your temperature may increase slightly immediately prior to ovulation."
B. "You should take your temperature before getting up for the day."
A nurse is reviewing the laboratory report of a client who is 24 hr postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take? a. Initiate IV access for isotonic solution with an 18-gauge catheter b. Prepare the client for a blood transfusion c. Administer an iron supplement to the client d. Instruct the client that the provider will check for placental fragments
C. Administer an iron supplement to the client ( I think, see rationale below) B. Prepare the client for a blood transfusion?? ATI: "Severe anemic clients can receive blood transfusions" another exam said this one though so idk C. Administer an iron supplement to the client-ATI "Iron supplements can be prescribed for clients who have low hgb and hct levels." do iron supplements first, then blood transfusion?
A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? a. Keep the newborn in a side-lying position b. Restrict the newborn's fluid intake c. Cover the newborn's bladder with a sterile, non-adherent dressing d. Exert gentle pressure on the newborn's bladder with sterile gauze
Cover the newborn's bladder with a sterile, non-adherent dressing -to prevent infection? Since bladder is exposed to environment Exstrophy of the bladder - protrusion of the urinary bladder through a defect in the abdominal wall.
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider? a. DTR 2+ b. Absence of clonus c. Facial flushing d. Urine output 20 mL/hr
D. Urine output 20 mL/hr - signs of magnesium sulfate toxicity: urine output < 30 mL/hr
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs a. Six contractions in 10 mins b. Moderate variability of the fetal heart rate c. Nonrepetitive.early decals d. Contractions last 60 secs
a. Six contractions in 10 mins a. Six contractions in 10 mins b. Moderate variability of the fetal heart rate c. Nonrepetitive.early decals d. Contractions last 60 secs 3 contractions within a 10 minute period 5 or more contractions in 10 mins OR contractions longer than 90 seconds = hyperstimulation of uterus - avoid
A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor? a. Chorioamnionitis b. Vaginal laceration during birth c. Excessive bleeding after birth d. Oligohydramnios
NOT SURE ABOUT THIS ONE A, C, D? a. Chorioamnionitis b. Vaginal laceration during birth c. Excessive bleeding after birth - i think, b/c the site said bleeding can occur, ATI just said PID "pelvic inflammatory disease" d. Oligohydramnios (associated w/ congenital anomalies) Rationale: http://americanpregnancy.org/pregnancy-complications/gonorrhea-during-pregnancy/
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 delivers the newborn b. The client expels the placenta c. The client beings having regular contractions d. The client experiences gradual dilation of the cervix
a. The client delivers the newborn a. The client delivers the newborn (PDF p.73: 2nd stage--birth) b. The client expels the placenta (3rd stage) c. The client beings having regular contractions (1st stage, active phase) d. The client experiences gradual dilation of the cervix (1st stage, active phase)
A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first? a. Reposition the client b. Apply an ice pack to the client's perineum c. Assess the client's perineal area for swelling d. Administer ibuprofen to the client
c. Assess the client's perineal area for swelling
A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position (LOA). On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the FHR?
Place the fetal monitor on the bottom left box (LLQ)
A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates a complication? (ATI p.118) a. Hypotonic uterus b. Hct 36% c. Platelet count 370,000/mm d. Perineal edema
a. Hypotonic uterus b. Hct 36% - 36-48 c. Platelet count 370,000/mm - 150-450k d. Perineal edema - normal finding after giving birth Atypical uterine contraction patterns prevent the normal process of labor & its progression. Contraction can be HYPOTONIC (weak, inefficient, or completely absent)
A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings? a. Newborn has fewer than 4 wet diapers in 24hrs b. The newborn's cord stump is will attach after 1 week c. The newborn sleeps 16hrs a day d. The newborn has loose stools
a. Newborn has fewer than 4 wet diapers in 24hrs a. Newborn has fewer than 4 wet diapers in 24hrs- ( 6-8/day) b. The newborn's cord stump is will attach after 1 week - ( falls off around 10-14 days) c. The newborn sleeps 16hrs a day- (normal 16-19 hours/day) d. The newborn has loose stools - (normal from milk)
A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? a. Temperature 36.5℃ (97.7℉) b. Blood pressure 80/50 mm Hg c. Respiratory rate 55/min d. Heart rate 72/min
d. Heart rate 72/min a. Temperature 36.5℃ (97.7℉) - (97.7-98.9'F // 36.5-37.2'C) b. Blood pressure 80/50 mm Hg (60-80 systolic & 40-50 diastolic) c. Respiratory rate 55/min (30-60/min) d. Heart rate 72/min - (100-160=/min) (ATI p.156-157)
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take? a. Inform the client that the law requires her to name the fetus b. Limit the amount of time the fetus is in the client's room c. Instruct the client that an autopsy should be performed within 24 hr. d. Prepare the client for what to expect the fetus to look like.
d. Prepare the client for what to expect the fetus to look like.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply) a. History of human papillomavirus b. Vacuum-assisted delivery c. Labor induction with oxytocin d. Newborn weight 2.948 kg (6 lb 8 oz) e. History of uterine atony
(ATI pg.145) Both C & E a. History of human papillomavirus b. Vacuum-assisted delivery c. Labor induction with oxytocin d. Newborn weight 2.948 kg (6 lb 8 oz) - nahh this a skinny babbbby e. History of uterine atony (ATI pg.145)
A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth. Identify the sequence when performing suction with a bulb syringe. (move steps into box on the right) PUT IN ORDER 1. Compress the bulb syringe 2. Place the bulb syringe in the newborn's mouth 3. Use the bulb syringe to suction the newborn's nose 4. Assess the newborn for reflex bradycardia
1. Compress the bulb syringe 2. Place the bulb syringe in the newborn's mouth 3. Use the bulb syringe to suction the newborn's nose 4. Assess the newborn for reflex bradycardia
A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease. Available is metronidazole 500 mg tablets. How many tablets should the nurse administer? (Round to nearest whole number)
2000 mg/500 mg = 4 tabs
A nurse is planning care for a newborn who is large for gestational age due to maternal gestational diabetes mellitus. The nurse should recognize that the newborn is at risk for which of the following conditions (select all that apply) a. Polycythemia b. Hypermagnesemia c. Hypoglycemia d. Hyperbilirubinemia e. Hypercalcemia
A,C,D a. Polycythemia b. Hypermagnesemia c. Hypoglycemia d. Hyperbilirubinemia e. Hypercalcemia - hypo Lowdermilk PDF 841 Infants born to mothers with diabetes are at increased risk for complications such as congenital anomalies, macrosomnia, birth trauma, pernatal asphyxia, stillbirth, preterm birth, respiratory distress syndrome (RDS), HYPOGLYCEMIA, hypocalcemia, hypomagnesemia, cardiomyopathy, HYPERBILIRUBINEMIA, and POLYCETHEMIA.
A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain. (Select all that apply) a. Perform Leopold maneuvers b. Have the client sit in a tub of warm water c. Ambulate the client in the hallway d. Administer 70% nitrous oxide mixed with o2 e. Apply counterpressure to the sacral area
C&E a. Perform Leopold maneuvers b. Have the client sit in a tub of warm water- page 434. Warm baths help prolong labor (another test chose this answer- why prolong when client is in labor and in pain?) c. Ambulate the client in the hallway- p. 434 d. Administer 70% nitrous oxide mixed with o2- p. 407 lowedmilk, nitric oxide can be mixed with o2 but it has to be LESS than 50 % e. Apply counterpressure to the sacral area - page 393 lowdermilk, tennis ball , fist or heel to apply in lower back due to pain caused by pressure from the occiput againes the spinal nerves.
A nurse is caring for a cline who is in the first stage of labor & the fetal head is in a posterior position. The client reports pressure and pain in her lower back. Which of the following non-pharmacological comfort measure should nurse suggest first? a. Effleurage b. Patterned breathing c. Counterpressure d. Guided imagery
Counterpressure a. Effleurage → light, gentle circular stroking on pt.'s belly w/ fingertips in rhythm w/ breathing during contractions b. Patterned breathing c. Counterpressure- - counteracts lower back pain by consistently applying pressure to the pt.'s sacral area using the heel of your hand or fist d. Guided imagery
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 est. date of delivery.
March 8, minus 3 months plus 7 days and 1 year equals an estimated date of delivery of December 15
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first? a. Assist the client to the bathroom b. Offer the client a sitz bath c. Insert a urinary catheter d. Pour warm water over the client's perineum
a. Assist the client to the bathroom
A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concerns about preparing her 2-year old child for a new a sibling. Which of the following is an appropriate response by the nurse? a. "Move your toddler to his new bed 2 months before the baby comes home." b. "Let your toddler see you carrying the baby into the home for the first time." c. "Avoid bringing your toddler to prenatal visits." d. "Require scheduled interactions between the toddler and the baby."
a. "Move your toddler to his new bed 2 months before the baby comes home." b. "Let your toddler see you carrying the baby into the home for the first time." (have someone else carry the baby so you can hug the child first) c. "Avoid bringing your toddler to prenatal visits." d. "Require scheduled interactions between the toddler and the baby." (Dont force it, often will be more interested in mommy's love) ● Move the child to a bed (if still sleeping in a crib) at least 2 months before the baby is due. Do not force interactions between the child and the baby
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus 𝛃𝛃 hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? a. "We need to know if you are positive for GBS at the time of delivery." b. "There was no indication of GBS in your earlier prenatal testing." c. "You didn't report any symptoms of GBS during your pregnancy." d. "Your previous deliveries were all negative for GBS."
a. "We need to know if you are positive for GBS at the time of delivery." Rational: GBS testing isn't performed until 35 to 37 weeks of gestation Testing within 5 weeks of delivery - most accurate at predicting GBS at birth. Bacteria can come and go. Result of an early test not a good predictor of whether you'll have the bacteria when you give birth
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. "You should expect your uterus to double in size." b. "Your stomach will empty rapidly." c. "Your nipples will become lighter in color." d. "You should anticipate nasal stuffiness."
a. "You should expect your uterus to double in size."
A nurse on the labor and delivery unit is caring for a client who is at 33 weeks of gestation and was admitted with placenta previa. Which of the following interventions should the nurse include in the client's plan of care? a. A non-stress test twice weekly b. Administration of magnesium sulfate c. Routine vaginal exams d. Ambulation as tolerated
a. A non-stress test twice weekly a. A non-stress test twice weekly - noninvasive b. Administration of magnesium sulfate (if patient was having contractions- Another test said this answer) c. Routine vaginal exams - avoid d. Ambulation as tolerated - bed rest Lowdermilk 682 If bleeding stops, Fetal surveillance may include a nonstress test (NST) or biophysical profile (BPP) once or twice weekly. Lowdermilk 683 Mag Sulfate can be given for tocolysis (ant-contraction) if uterine contractions are identified.
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. Avoid using lotion or ointment on the newborn's skin b. Dress the newborn in lightweight clothing c. Keep the newborn supine throughout treatment d. Measure the newborns temp q8hrs
a. Avoid using lotion or ointment on the newborn's skin a. Avoid using lotion or ointment on the newborn's skin- (absorbs too much heat and may lead to burn injury) b. Dress the newborn in lightweight clothing - (diaper only) c. Keep the newborn supine throughout treatment d. Measure the newborns temp q8hrs *Cover eyes. Newborn undressed but cover genitals. No lotion! Remove baby from phototherapy every 4 hours. Reposition every 2 hrs. Bronze discoloration of baby is normal.
A nurse on the postpartum unit is reviewing prevention of new diaper rash with a client. Which of the following statements indicates an understanding of the teaching? a. I will allow the diaper area to dry before applying clean diaper b. I will clean the diaper area with a scented baby wipe c. I will apply a thin layer of tail to the diaper area twice a day d. I will wash the diaper area with an antibacterial soap with each diaper change
a. I will allow the diaper area to dry before applying clean diaper a. I will allow the diaper area to dry before applying clean diaper b. I will clean the diaper area with a scented baby wipe c. I will apply a thin layer of tail to the diaper area twice a day d. I will wash the diaper area with an antibacterial soap with each diaper change ATI OB 305 To avoid diaper rash, the newborn's diaper area should be kept clean and dry. Diapers should be changed frequently, and the perineal area cleaned with warm water or wipes and dried thoroughly to prevent skin breakdown.
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 30-60 min b. Maintain the client in a supine position c. Limit IV intake to 4 L per 24 hr d. Titrate the infusion rate by 4 milliunits/min
a. Increase the infusion rate every 30-60 min ATI pg 254: Use an infusion pump to administer IV oxytocin. Gradually increase the flow rate per prescribed parameters, such as 1 milliunits/min every 30 to 60 min
A nurse is assessing a full term newborn 1 hr following a vaginal birth. Which of the following is an expected assessment finding? a. The newborn's head circumference is greater than the chest circumference b. The newborn exhibits apnea episodes of 30 seconds c. The newborn has a heart rate of 70/min while sleeping d. The newborn's anterior fontanelle bulges when he is quiet
a. The newborn's head circumference is greater than the chest circumference a. The newborn's head circumference is greater than the chest circumference - (PDF p.157: Head should be 2 to 3 cm larger than chest circumference) b. The newborn exhibits apnea episodes of 30 seconds - (PDF p.126: Too long; RR varies from 30 to 60 breaths/min with short periods of apnea (less than 15 seconds) c. The newborn has a heart rate of 70/min while sleeping - (PDF p.126: Too low; HR ranges from 110 to 160/min with brief fluctuations above and below this range depending on activity level) d. The newborn's anterior fontanelle bulges when he is quiet - (PDF p.157: Fontanels can bulge when the newborn cries, coughs or vomits, and are flat when the newborn is quiet)
A nurse is providing discharge instructions to a client who is 24 hr postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching? a. "Shower daily, allowing warm water to run directly over your breasts." b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule." c. "Wear a loose-fitting, nonbinding bra for 72 hours." d. "Pump your breasts twice daily to relieve discomfort from engorgement."
b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule." (ATI pg.139) a. "Shower daily, allowing warm water to run directly over your breasts." - avoid warm water b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule." c. "Wear a loose-fitting, nonbinding bra for 72 hours." - well fitting, supportive bra d. "Pump your breasts twice daily to relieve discomfort from engorgement." - cold compress/cold cabbage, mild analgesics or anti-inflammatory meds for pain & discomfort of engorgement
A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? a. "You can take 400 milligrams of ibuprofen for discomfort." b. "You should take 600 micrograms of folic acid per day." c. "You can take black cohosh once a day for insomnia." d. "You should limit your daily fluid intake to 1,000 milliliters per day."
b. "You should take 600 micrograms of folic acid per day." ATI pg 25: The March of Dimes recommends that clients who wish to become pregnant and clients of childbearing age take 400 mcg of folic acid and clients who become pregnant take 600 mcg of folic acid
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? a. A client who is at 37 weeks gestation and has an L/S ratio of 2:1 b. A client who is at 35 weeks of gestation and has a biophysical profile of 6 c. A client who is at 39 weeks of gestation and has a negative contraction stress test d. A client who is at 28 weeks of gestation and has a negative Coombs' titer
b. A client who is at 35 weeks of gestation and has a biophysical profile of 6 a. A client who is at 37 weeks gestation and has an L/S ratio of 2:1 - A 2:1 ratio indicates fetal lung maturity b. A client who is at 35 weeks of gestation and has a biophysical profile of 6 BPP: nonstress test + ultrasound (normal: 8-10) (abnormal: 4-6 - suspect chronic fetal asphyxia) (abnormal: <4 - strongly suspect chronic fetal asphyxia) c. A client who is at 39 weeks of gestation and has a negative contraction stress test (negative = normal finding ) d. A client who is at 28 weeks of gestation and has a negative Coombs' titer (normal - antibody test Rh antigen)
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hour postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? a. Respiratory rate 14/min b. Blood pressure 142/92 mm Hg c. Urine output 100 mL in 3 hr d. Pulse 58/min
b. Blood pressure 142/92 mm Hg Boggy uterus - cause of postpartum hemorrhage Argot alkaloid: given to stop excessive bleeding - monitor BP prior to administration
A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statements by the client requires immediate intervention by the nurse a. My feet are really swollen today b. I have been seeing spots this morning c. I didn't have lunch today but I had breakfast this morning d. It burns when I urinate
b. I have been seeing spots this morning a. My feet are really swollen today - (PDF p.22: lower-extremity edema can occur during the second and third trimesters) b. I have been seeing spots this morning - (PDF p.60: Visual disturbances (blurring of vision, flashes of lights or dots before the eyes) are s/s of severe preeclampsia & can lead to seizure activity aka eclampsia) c. I didn't have lunch today but I had breakfast this morning d. It burns when I urinate - (s/s of UTI--not as urgent)
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following statements by the client indicates an understanding of the teaching? a. I should use a nipple shield while breastfeeding b. I should apply lanolin to the infection site daily c. I should apply warm compresses after the feeding d. I should stop breastfeeding until the infection has healed
b. I should apply lanolin to the infection site daily a. I should use a nipple shield while breastfeeding (between feeding) b. I should apply lanolin to the infection site daily c. I should apply warm compresses after the feeding - Encourage the client to use ice packs or warm packs on affected breasts for discomfort d. I should stop breastfeeding until the infection has healed -continue breastfeeding frequently (Q2-4hr), especially on the affected side **Use Warm compress BEFOREfeeding → Cold AFTER
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following info should the nurse include? a. Yellow exudate will form at the surgical site in 24 Hours b. Notify the provider if the end of your baby penis appears dark red c. Make sure the newborn's diaper is snug d. The Plastibell will be removed 4 hrs after the procedure
b. Notify the provider if the end of your baby penis appears dark red a. Yellow exudate will form at the surgical site in 24 Hours - film of yellowish mucus can form over the glans by DAY TWO - important not to wash it off (this answer was chosen for another test). b. Notify the provider if the end of your baby penis appears dark red - notify provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination c. Make sure the newborn's diaper is snug - avoid wrapping tightly d. The Plastibell will be removed 4 hrs after the procedure - drops off after 5-7 days ATI p 178
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements 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 a. Premenstrual tension will no longer be present → menstruation still remain the same as before the sterilization. b. Ovulation will remain the same → tubal ligation does not change your menstrual cycle - still ovulate and have menstrual periods c. Hormone replacements will be needed following this procedure → no change in hormones and their influence. d. My monthly menstrual period will be shorter
A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask b. Place newborn bassinets at least 3 feet apart c. Place the newborn's foot on a sterile field during a heelstick d. Maintain airborne precautions in the nursery
b. Place newborn bassinets at least 3 feet apart
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. Swaddle the newborn in a flexed position c. Weigh the newborn every other day d. Discourage prenatal interaction until after a social service evaluation
b. Swaddle the newborn in a flexed position a. Increase the newborn's visual stimulation - (decrease stimulation) b. Swaddle the newborn in a flexed position (reduce stimulation and protect skin from abrasions) c. Weigh the newborn every other day - (Q day) d. Discourage prenatal interaction until after a social service evaluation Interventions-offer small feedings, swaddle newborn with legs flexed, reduce environmental stimuli
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? a. Respiratory rate 14/min b. Urinary output 20 ml/hr c. BP 148/94 mmHg d. 2+ deep tendon reflexes
b. Urinary output 20 ml/hr a. Respiratory rate 14/min b. Urinary output 20 ml/hr c. BP 148/94 mmHg d. 2+ deep tendon reflexes (PDF p.60: Magnesium sulfate toxicity - absent tendon reflex, urine output <30ml/hr, RR <12/min, decreased LOC, cardiac dysrhythmias)
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? (select all that apply) a. Respiratory rate 11/min b. Urine output 130 mL/4 hr c. Deep-tendon reflexes absent d. Fetal heart rate 120/min e. Flushing of the face
both A&C a. Respiratory rate 11/min - 12-20/min b. Urine output 130 mL/4 hr - normal c. Deep-tendon reflexes absent d. Fetal heart rate 120/min - normal (100-160/min) e. Flushing of the face - expected SE
A nurse is caring for a client who is 2 days postpartum and states, "I want to continue breastfeeding, but my nipples are so sore." Which of the following responses should the nurse make? a. "Removing breast shields from your bra will decrease discomfort." b. "You should switch your infant to formula until the soreness goes away." c. "Allow expressed milk to air dry on the nipples after feeding your infant." d. "Apply an antibiotic ointment to the nipples prior to each feeding."
c. "Allow expressed milk to air dry on the nipples after feeding your infant."
A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has molding with overlapping suture lines b. A female newborn who has blood-tinged vaginal discharge c. A newborn who has a high-pitched cry with exaggerated Moro reflex d. A male newborn who has scrotal edema
c. A newborn who has a high-pitched cry with exaggerated Moro reflex a. A newborn who has molding with overlapping suture lines - normal from head compression during labor b. A female newborn who has blood-tinged vaginal discharge - normal for newborns (crystals in urine) c. A newborn who has a high-pitched cry with exaggerated Moro reflex - hypoglycemia d. A male newborn who has scrotal edema
A nurse is caring for a client who has preeclampsia and is receiving mag sulfate by continuous IV infusion. The nurse should monitor for which of the following adverse effects? a. Elevated BP b. Hypertonia c. Absence of deep tendon reflexes d. Polyuria
c. Absence of deep tendon reflexes a. Elevated BP b. Hypertonia c. Absence of deep tendon reflexes d. Polyuria ATI Pharm 398 Assess for depressed or absent deep tendon reflexes as a sign of toxicity. Calcium gluconate is given for magnesium sulfate toxicity.
A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? a. Cap succedaneum b. Milia c. Bulging fontanels d. Subconjunctival hemorrhage
c. Bulging fontanels a. Cap succedaneum- p. 158- collection of blood that does not cross the suture line, resolves in 3-4 days. b. Milia- small raised white spot that will disappear on their own. Parents do not pop them. c. Bulging fontanels- can indicate infection, hemorrhage, or increased intracranial pressure. Ch 23 page 157 d. Subconjunctival hemorrhage - clears up on its own, artificial tears is usually used.
A nurse is providing teaching to a client who is postpartum about car seat safety. Which of the following statements by the client indicates an understanding of the teaching a. I will fasten the harness clip 1 in about my baby underarms b. I will swaddle my baby in a blanket before putting her in the car seat c. I will ensure that my baby is position 45 degree angle in the car seat d. I will put my baby facing forward in the middle of the back of the seat of the car
c. I will ensure that my baby is position 45 degree angle in the car seat a. I will fasten the harness clip 1 in about my baby underarms b. I will swaddle my baby in a blanket before putting her in the car seat c. I will ensure that my baby is position 45 degree angle in the car seat d. I will put my baby facing forward in the middle of the back of the seat of the car - - rear facing
A nurse is teaching a client who is pregnant about a new prescription for iron supplements. Which of the following instructions should the nurse include in the teaching. a. Take an extra pill if you miss a dose b. Drink 8oz of milk with each pill c. Increase intake of food rich in vitamin C d. Report black stools to the provider
c. Increase intake of food rich in vitamin C a. Take an extra pill if you miss a dose b. Drink 8oz of milk with each pill c. Increase intake of food rich in vitamin C d. Report black stools to the provider rationale: It enhances body's absorption of iron by drinking or eating foods rich in vitamin C.
A nurse is reviewing the Immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy? a. Varicella b. Rubella - live vaccine c. Tetanus d. Rubeola
c. Tetanus Rationale: Tdap & inactivated influenza are recommended
A nurse is conducting a class for a group of clients about birth control. Which of the following information should the nurse include in the teaching? a. You should have an annual exam to assess your diaphragm b. Your fertility will return 6 months after your provider removes your IUD c. You should use spermicide 3 hrs. prior to sexual intercourse d. You will not need to use birth control for 1 month after receiving emergency contraception
c. You should use spermicide 3 hrs. prior to sexual intercourse a. You should have an annual exam to assess your diaphragm - every 2 years b. Your fertility will return 6 months after your provider removes your IUD - Contraception can be reversed with immediate return to fertility) c. You should use spermicide 3 hrs. prior to sexual intercourse (PDF p.5: Up to 6 hours before intercourse) d. You will not need to use birth control for 1 month after receiving emergency contraception - (PDF p.6: Does not provide long-term contraception so still need to use contraception regularly after)
A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks gestation and has preeclampsia. Which of the following responses by the nurses is appropriate? a. "This medication improves tissue perfusion." b. "This medication increases cardiac output." c. "This medication stabilizes the fetal heart rate." d. "This medication prevents seizures."
d. "This medication prevents seizures." Magnesium sulfate - tocolytics = uterine muscle relaxation. Primary use: prevent seizures in clients who have preeclampsia
A nurse in a provider's office is caring for a 20-year old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? (ATI pg.43-44) a. "We can schedule the procedure for later today if you'd like." b. "You cannot have an amniocentesis until you are at least 35 years of age." 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."
d. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby." not Amniocentesis isn't performed until 14 weeks of gestation and a CVS can act as a 1st trimester alternative for an amniocentesis. CVS's are ideally performed at 10-13 weeks of gestation!
A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports abdominal pain during breastfeeding b. A client who reports changing her perineal pad every 2 hr c. A client who has a urine output of 250 mL in 6 hr d. A client who has hyporeflexia while receiving IV magnesium sulfate
d. A client who has hyporeflexia while receiving IV magnesium sulfate - can indicate toxicity
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent DTR's. Which of the following medications should the nurse administer a. Phytonadione b. Acetylcysteine c. Protamine Sulfate d. Calcium gluconate
d. Calcium gluconate - antidote
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. Telangiectatic nevi b. Periauricular papillomas c. Erythema toxic d. Facial petechiae
d. Facial petechiae- seen over the presenting part with soft tissue injuries -Nuchal cord: umbilical cord around fetal neck. Will cause variable deceleration of FHR. Intervention: reposition client from side to side or into knee chest, discontinue oxytocin if being infused, oxygen a. Telangiectatic nevi - stork bites; flat pink or red marks that easily blanch & are found on the back of the neck, nose, upper eyelid, and middle of the forehead; usually fade by 2nd year of life b. Periauricular papillomas c. Erythema toxic - newborn rash d. Facial petechiae
A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication to the administration of which of the following medications? a. Azithromycin b. Metformin c. Diphenhydramine d. Istotretinoin
d. Istotretinoin - also called Accutane; highly teratogenic
A nurse in a prenatal clinic is reviewing the lab results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take (EXHIBIT QUESTION) a. Administer ceftriaxone IM b. Administer rubella vaccine c. Obtain a maternal alpha-fetoprotein specimen d. Obtain a blood culture
d. Obtain a blood culture a. Administer ceftriaxone IM - isn't this cross sensitive to PCN allergy though? ; cephalosporin; can't give w/ PCN allergy; check PHARM pg 358 b. Administer rubella vaccine - given for titer <1:8 - contraindicated for pregnant women c. Obtain a maternal alpha-fetoprotein specimen - done between 16-18 weeks of gestation d. Obtain a blood culture - hmmm
A nurse is assisting with precipitous delivery of a term newborn. After the head emerges, the nurse palpates the cord around the newborn's neck. Which of the following actions should the nurse take? a. Apply fundal pressure b. Place the client in the knee-chest position c. Apply a water-based lubricant to the cord d. Slip the cord over the newborn's head
d. Slip the cord over the newborn's head (ATI pg. 119) precipitous labor - is labor that lasts 3 hours or less from the onset of contractions to the time of delivery If the cord is around the fetal neck attempt to gently slip it over the head, if not possible clamp the cord w/ 2 clamps & cut b/w the clamps
A nurse is assessing a full term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider a. Single palmar creases b. Rust stained urine c. Subconjunctival hemorrhage d. Transient circumoral cyanosis
d. Transient circumoral cyanosis a. Single palmar creases - "simian crease" indication of down syndrome b. Rust stained urine - normal in newborns c. Subconjunctival hemorrhage - caused by pressure during pregnancy but goes away d. Transient circumoral cyanosis - bluish tint in area surrounding the lips (possible indication of respiratory distress or hypothermia)
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make? a. If you don't hold the baby it will make letting go much harder b. I'm sure you will be able to have another baby when you are ready c. You should name the baby so she can have an identity d. You can bathe and dress your baby if you'd like so
d. You can bathe and dress your baby if you'd like so a. If you don't hold the baby it will make letting go much harder b. I'm sure you will be able to have another baby when you are ready c. You should name the baby so she can have an identity d. You can bathe and dress your baby if you'd like so Fetal demise- stillbirth or neonatal death; process of CLOSURE
A nurse if caring for a client who is postpartum following repair of a vaginal laceration. The client has a firm fundus, moderate lochia rubra & reports moderate perineal discomfort & pressure. Which of the following actions should the nurse take? a. Check the perineal area b. Perform deep fundal massage c. Administer methylergonovine 0.2 mg IM d. Obtain a vaginal culture
a. Check the perineal area a. Check the perineal area - (PDF p.119: Assess first! Assess episiotomy and lacerations for approximation, drainage, quantity, and quality) b. Perform deep fundal massage c. Administer methylergonovine 0.2 mg IM - for postpartum hemorrhage d. Obtain a vaginal culture
A nurse is caring for a client who is active labor & is receiving oxytocin via IV infusion. The nurse has applied an internal fake heart monitor & recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take? a. Continue to monitor the client b. Discontinue oxytocin c. Administer 8L/min per mask d. Assists the client to lay on her right side
a. Continue to monitor the client a. Continue to monitor the client b. Discontinue oxytocin c. Administer 8L/min per mask d. Assists the client to lay on her right side OB ati pg 88: early decelerations are slowing of FHR w/start of contraction w/return of FHR to baseline at end of contraction. Likely caused by fetal head compression resulting from uterine contraction. No intervention is required
A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take? a. Demonstrate how to hold the newborn and allow the client to practice b. Persuade the client to breastfeed the newborn to promote bonding c. Offer to take the newborn to the nursery to finish his feeding d. Insist that the mother pick up the newborn to feed him
a. Demonstrate how to hold the newborn and allow the client to practice
A nurse is caring for a preterm newborn immediately after delivery. Which of the following actions should the nurse takes first? a. Dry the infant under a radiant warmer b. Weigh the infant c. Take the infant's temp d. Obtain the infant's blood glucose level
a. Dry the infant under a radiant warmer a. Dry the infant under a radiant warmer b. Weigh the infant c. Take the infant's temp d. Obtain the infant's blood glucose level ● Preterm newborn- birth occurs within week 20-37 ● Maintain thermoregulation in newborn who is preterm by using heat warmer. ● Manifestation of hypothermia: apnea, cyanosis, hypoglycemia, feeding intolerance, lethargy)
A nurse in a postpartum unit is caring for several clients. Which of the following tasks should the nurse delegate to assistive personnel? a. Help the client with perineal care b. Check the saturation of the perineal pad c. Provide the client with a dose of magnesium hydroxide d. Demonstrate to a client how to change a diaper
a. Help the client with perineal care a. Help the client with perineal care - (CNA=hygiene, ADLs) b. Check the saturation of the perineal pad - (RN=Assess) c. Provide the client with a dose of magnesium hydroxide - (RN=Medication administration) d. Demonstrate to a client how to change a diaper - (RN=Teach)
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? a. Lentils b. Oatmeal c. Cabbage d. Asparagus
a. Lentils (16g boiled)
A nurse is performing a physical examination of a term newborn upon admission to the nursery. In which order should the nurse perform the following assessments? a. Observe the newborns respirations b. Auscultate the newborn's heart rate c. Auscultate the newborns abdomen d. Test the newborn's reflexes (this is already in order FYI)
a. Observe the newborns respirations b. Auscultate the newborn's heart rate c. Auscultate the newborns abdomen d. Test the newborn's reflexes (PDF p.156: Vital signs are checked in the following sequence: respirations, heart rate, blood pressure, and temperature. The nurse observes the respiratory rate first before the newborn becomes active or agitated by use of the stethoscope, thermometer, and/or blood pressure cuff)
A nurse is reviewing the laboratory findings of a client who is at 10 wks gestation. Which of the following findings should the nurse report to the provider a. Platelets 100,000 mm3 b. WBC count 10,000mm3 c. Hgb 12g/dL d. Creatinine 0.5mg/dL
a. Platelets 100,000 mm3 a. Platelets 100,000 mm3- (150,000-300,000) b. WBC count 10,000mm3 c. Hgb 12g/dL d. Creatinine 0.5mg/dL
A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse effect a. Maternal hypertension b. Decreased ability to bear down c. Fetal bradycardia d. Uterine hyperstimulation
b. Decreased ability to bear down a. Maternal hypertension b. Decreased ability to bear down - compromise of maternal bearing down reflex c. Fetal bradycardia d. Uterine hyperstimulation *NO maternal/fetal systemic effects. Suitable during 2nd and 3rd stage of labor and for repair of episiotomy and lacerations. A local anesthesia to the perineum, vulva, and rectal areas during delivery. Given in 2nd stage of labor. 20 minutes before delivery. Provides analgesia before expulsion of the fetus. ADVERSE effects: broad ligament hematoma, compromise of material of bearing down reflex
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 b. Mothers will receive prophylactic treatment with acyclovir prior to delivery c. Lesions are visible on the mother's genitalia d. This infection requires airborne precautions are initiated for the newborn
a. Transmission can occur via the saliva and urine of the newborn a. Transmission can occur via the saliva and urine of the newborn (semen, cervical/vag secretions, breast milk, placental tissue, urine, feces, blood) b. Mothers will receive prophylactic treatment with acyclovir prior to delivery - (ganciclovir) c. Lesions are visible on the mother's genitalia d. This infection requires airborne precautions are initiated for the newborn (droplet)
1. A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection? a. Unilateral breast pain b. Persistent abdominal striae c. Lochia alba d. WBC count 12,000/mm
a. Unilateral breast pain a. Unilateral breast pain- indicative of mastitis b. Persistent abdominal striae c. Lochia alba - malodorous or purulent d. WBC count 12,000/mm - (this one's elevated too) ATI pg 143: Postpartum infections - can occur up to 28 days following childbirth. Fever of 100.4℉ or higher for 2 consecutive days during the first 10 days postpartum
A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? a. "Limit your fluid intake to four 8-ounce glasses per day." b. "Count your baby's movements daily." c. "Reduce your calcium intake to less than 1 gram per day." d. "Alternate arms each time you check your blood pressure."
b. "Count your baby's movements daily." a. "Limit your fluid intake to four 8-ounce glasses per day." - 6 to 8, 8oz glasses of water a day b. "Count your baby's movements daily." c. "Reduce your calcium intake to less than 1 gram per day." d. "Alternate arms each time you check your blood pressure." - same arm, position, time every day
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? a. "You will have dilation and effacement of the cervix." b. "Your contractions will become temporarily regular." c. "You will have bloody show." d. "Your contractions will become more intense when walking."
b. "Your contractions will become temporarily regular." - B says "temporarily"
A nurse is providing vehicle safety education to the parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. "You should secure your newborn's car seat at a 60-degree angle." b. "Your newborn will need to have a car seat test prior to discharge." c. "Place your newborn in a front-facing car seat in the back seat of the vehicle." d. "Position the retainer clip at the level of your newborn's abdomen."
b. "Your newborn will need to have a car seat test prior to discharge." a. "You should secure your newborn's car seat at a 60-degree angle." - no more than 45 b. "Your newborn will need to have a car seat test prior to discharge." c. "Place your newborn in a front-facing car seat in the back seat of the vehicle." - rear facing d. "Position the retainer clip at the level of your newborn's abdomen." - about armpit level
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 breast milk that is unused can be refrozen." b. "Breast milk can be stored at room temperature for up to 12 hours." c. "Breast milk can be stored in a deep freezer for 12 months." d. "Thawed breast milk can be refrigerated for up to 72 hours."
b. 8 hrs c. "Breast milk can be stored in a deep freezer for 12 months." d. up to 24 hrs
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? a. Offer the newborn 30mL (1 oz) of water between feedings b. Allow the baby to feed at least every 2 hrs c. Feed the newborn 5-10 mins per breast d. Expect 2 -4 wet diapers every 24 hrs
b. Allow the baby to feed at least every 2 hrs (ATI p.180) a. Offer the newborn 30mL (1 oz) of water between feedings b. Allow the baby to feed at least every 2 hrs (q 2-3 hrs) c. Feed the newborn 5-10 mins per breast - at least 15-20 minutes d. Expect 2 -4 wet diapers every 24 hrs ( 6-8 diapers) Should breastfeed Q 2-3 hours for the first 6 months. Should occur 8-12 times a day. And feed on demand. Cramps are normal during breastfeeding. Stimulating the nipple causes let down reflex of milk.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take? a. Offer supplemental formula between the newborn's feedings b. Assess the newborn's latch while breastfeeding c. Instruct the client to wait 4 hrs between daytime feedings d. Have the client limit the length of breastfeeding to 5 min per breast
b. Assess the newborn's latch while breastfeeding a. Offer supplemental formula between the newborn's feedings b. Assess the newborn's latch while breastfeeding c. Instruct the client to wait 4 hrs between daytime feedings d. Have the client limit the length of breastfeeding to 5 min per breast
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Respiratory rate 18/min b. Cool, clammy skin c. Urinary output 30 mL/hr d. Bounding pulses
b. Cool, clammy skin a. Respiratory rate 18/min - inc rr b. Cool, clammy skin c. Urinary output 30 mL/hr - little/no uo d. Bounding pulses - weak pulses
A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help relieve this common discomfort of pregnancy? a. Include 18g of fiber in the diet each day (25 to 30g) b. Drink 2 to 3 L of water each day c. Add 30 mL of mineral oil to each meal d. Take 60 mL of magnesium hydroxide once daily
b. Drink 2 to 3 L of water each day ATI pg 22 - Encourage to drink plenty of fluids, eat a diet high in fiber, and exercise regularly
A nurse is providing discharge teaching to the parent of a newborn about surgical site care following circumcision using a clamp technique. Which of the following statements by the parent indicates understanding? a. I will check the site hourly for bleeding b. I will apply petroleum jelly to area with each diaper change c. I will remove the crust with each diaper change d. I will wash the penis with soap and water daily
b. I will apply petroleum jelly to area with each diaper change a. I will check the site hourly for bleeding b. I will apply petroleum jelly to area with each diaper change c. I will remove the crust with each diaper change - DO NOT wipe of yellow mucous d. I will wash the penis with soap and water daily
A nurse in a prenatal clinic is discussing quickening with a client who is in the first trimester of her first pregnancy. Which of the following statements by the client indicates understanding of the teaching a. I will begin scheduling appointments every 2 wks b. I will feel movement at about 16-20 wks c. I will take 2 ibuprofen capsules for the discomfort d. I will plan to have a blood test when quickening occurs
b. I will feel movement at about 16-20 wks a. I will begin scheduling appointments every 2 wks b. I will feel movement at about 16-20 wks c. I will take 2 ibuprofen capsules for the discomfort d. I will plan to have a blood test when quickening occurs *ATI OB 24 Quickening- slight fluttering movements of the fetus felt by a woman, usually between 16-20 weeks of gestation.
A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position which of the following methods should the nurse use to elicit the moro reflex? a. Touch the newborn cheek w/ a finger- b. Make a loud noise above the newborn c. Turn the newborn's head to one side d. Tap the newborn's forehead with a finger
b. Make a loud noise above the newborn ch 23 p . 159 a. Touch the newborn cheek w/ a finger- (rooting reflex) b. Make a loud noise above the newborn c. Turn the newborn's head to one side- (tonic neck reflex) d. Tap the newborn's forehead with a finger ● Moro reflex by striking a flat surface that the newborn is lying on, or allowing the head and trunk of the newborn in a semi sitting position to fall backward to an angle of at least 30°. ○ Arms and legs symmetrically extend and then abduct while fingers spread to form a "C."
A nurse is assessing a client immediately following the placement of an epidural. The nurse obtains a maternal blood pressure of 96/54 mmHg and a fetal heart rate of 102/min. which of the following actions should the nurse take? a. Administer naloxone to the client b. Position the client in a lateral position c. Place the client in knee chest position d. Prepare the client for an amnioinfusion
b. Position the client in a lateral position a. Administer naloxone to the client b. Position the client in a lateral position c. Place the client in knee chest position - (do this for variable deceleration and FHR) d. Prepare the client for an amnioinfusion - process of instilling normal saline in amniotic cavity into the uterus to supplement the amount of fluids to reduce variable decelerations cause by cord compression Administer a bolus of IV fluids to help offset maternal hypotension. IV fluids to compensate for the sympathetic blocking effects of regional anesthetics
A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? a. The client will identify individual family member roles b. The client will have adequate nutritional intake c. The client will verbalize appropriate car safety d. The client will demonstrate proper bathing of the infant
b. The client will have adequate nutritional intake a. The client will identify individual family member roles - letting go phase b. The client will have adequate nutritional intake c. The client will verbalize appropriate car safety - taking hold phase d. The client will demonstrate proper bathing of the infant - taking hold phase Taking in: focusing on meeting personal needs; rely on others for assistance Takin hold: want to learn and practice; focuses on baby Letting go: focus on family as a unit; resumption of role
A nurse is caring for a client who is in labor and is prescribed an amnioinfusion. Which of the following findings is an indication for this procedure? a. Fetal macrosomia b. Variable decelerations c. Early decelerations d. Increased uterine tone
b. Variable decelerations a. Fetal macrosomia b. Variable decelerations c. Early decelerations d. Increased uterine tone AMNIOINFUSION: process of instilling normal saline or LR in amniotic cavity into the uterus to supplement the amount of fluids to reduce variable decelerations caused by cord compression
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take? a. Instruct the client to avoid urinary elimination until after administration b. Verify that the informed consent is obtained prior to administration c. Allow the medication to reach room temp prior to administration d. Place the client in a semi fowler's position for 1 hr after administration
b. Verify that the informed consent is obtained prior to administration
A nurse is caring for a client who is 1 day postpartum following the birth of her first baby. The client's partner states they been having nightmares that we are homeless and the baby starving. Which of the following is appropriate response by nurse a. I know your worries but everything is going to be okay. b. What do you think it'll be like to be responsible for a baby? c. Why would you worry about being homeless when you have a good job d. This is just the beginning of the worrying you will do as a parent
b. What do you think it'll be like to be responsible for a baby? a. I know your worries but everything is going to be okay b. What do you think it'll be like to be responsible for a baby? Open-ended c. Why would you worry about being homeless when you have a good job d. This is just the beginning of the worrying you will do as a parent
A client and her partner ask the nurse for information about permanent contraception. Which of the following statements should the nurse include in the counseling? a. "A man is usually sterile immediately after a vasectomy" b. "The menstrual cycle is shorter after a tubal ligation" c. "Most sterilization procedures are considered irreversible" d. A woman should use contraception for 1-2 months after a tubal ligation"
c. "Most sterilization procedures are considered irreversible" a. "A man is usually sterile immediately after a vasectomy" use birth control for 20 ejaculations/1 week to several months = allow all of the sperm to clear the vas deferens b. "The menstrual cycle is shorter after a tubal ligation" - cut/burns/block fallopian tubes to prevent ovum from being fertilized c. "Most sterilization procedures are considered irreversible" d. A woman should use contraception for 1-2 months after a tubal ligation" Permanent contraception = sterilization
A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? a. "Insert the diaphragm up to 12 hours before intercourse." b. "Remove the diaphragm 2 hours after intercourse." c. "Replace the diaphragm every 2 years." d. "Use 2 teaspoons of baby oil to lubricate the diaphragm before insertion."
c. "Replace the diaphragm every 2 years." a. "Insert the diaphragm up to 12 hours before intercourse." - up to 6 hrs b. "Remove the diaphragm 2 hours after intercourse." - must stay on for up to 6 hrs after intercourse but no more than 24 hrs c. "Replace the diaphragm every 2 years." d. "Use 2 teaspoons of baby oil to lubricate the diaphragm before insertion." - insert spermicidal jelly or cream applied to the cervical side of the dome around the rim
A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? a. " I will insert a urinary catheter before I administer the medication" b. "I will begin an oxytocin infusion w/in 2 hrs of your last dose of medication" c. "You will lie on your side for 40 minutes after I administer the medication d. "You will receive an antacid containing magnesium before the medication"
c. "You will lie on your side for 40 minutes after I administer the medication (Misoprostol (Cytotec) - Uterine Stimulant. Controls postpartum hemorrhage.) a. " I will insert a urinary catheter before I administer the medication" b. "I will begin an oxytocin infusion w/in 2 hrs of your last dose of medication" - (w/in 6-12hs) c. "You will lie on your side for 40 minutes after I administer the medication d. "You will receive an antacid containing magnesium before the medication" - concurrent use = diarrhea
A nurse is caring for 4 clients. Which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit? a. Client who has positive urine pregnancy test 1 week after missed menses b. A client who has a crown rump length of 7 wks gestation c. A client who has an ultrasound that confirms molar pregnancy d. A client who has felt quickening for the first time
c. A client who has an ultrasound that confirms molar pregnancy a. Client who has positive urine pregnancy test 1 week after missed menses (not urgent, normal) b. A client who has a crown rump length of 7 wks gestation (normal) c. A client who has an ultrasound that confirms molar pregnancy (URGENT) d. A client who has felt quickening for the first time Rationale: Molar Pregnancy Appears when tissue that normally becomes a fetus instead becomes an abnormal growth in your uterus. Even though it isn't an embryo, this growth triggers symptoms of pregnancy. A molar pregnancy should be treated right away. This will make sure that all of the tissue is removed.
A nurse at an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first? a. A client who is at 8 weeks of gestation and reports severe vomiting b. A client who is at 36 weeks of gestation and reports back pain following intercourse c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers d. A client who is at 10 weeks gestation and reports frequent urination
c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers a. A client who is at 8 weeks of gestation and reports severe vomiting (hyperemesis gravidarum) - happens after 12 weeks b. A client who is at 36 weeks of gestation and reports back pain following intercourse (preterm labor?) c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers - hypoglycemic? d. A client who is at 10 weeks gestation and reports frequent urination ● Report of tingling sensations in the fingers indicates that the client is is hyperventilating, this causes respiratory alkalosis--results in dizziness, tingling of the fingers, and circumoral numbness. This can be reversed by having the client breathe into her cupped hands or placing a paper bag tightly around her mouth and nose to breathe carbon dioxide. ● Periodic numbness in the fingers occurs from the slumping of shoulders while pregnant and is an expected finding in the second semeste
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take? a. Apply an ice pack to the incision site. b. Replace the surgical dressing c. Administer 500 mL lactated ringer's IV bolus d. Evaluate urinary output
c. Administer 500 mL lactated ringer's IV bolus (initiate IV fluids to replace fluid volume loss w/ isotonic solution) ATI pg 136
A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take? a. Decrease the rate of IV fluids b. Elevate the client's head c. Administer oxygen via a face mask d. Perform fetal scalp stimulation
c. Administer oxygen via a face mask a. Decrease the rate of IV fluids - increase b. Elevate the client's head - side lying c. Administer oxygen via a face mask d. Perform fetal scalp stimulation Interventions for Late Decels: ● Place pt in side lying position ● Insert IV cath if not in place & INCREASE rate of IV fluid ● d/c oxytocin if it's infusing ● Admin O2 by mask at 8-10L/min via nonreabreather mask ● Elevate legs ● Notify provider ● Prepare for vaginal birth or C-section
A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the clients' perineum immediately following emergence. Which of the following actions should the nurse take? a. Assess fetal position using Leopold maneuvers . b. Reposition the client in a left lateral position c. Apply pressure to the clients suprapubic area d. Empty the client's bladder using Crede's maneuver
c. Apply pressure to the clients suprapubic area a. Assess fetal position using Leopold maneuvers - isn't this done before patient goes into labor b. Reposition the client in a left lateral position - what would this do? c. Apply pressure to the clients suprapubic area - for LGA newborns.. d. Empty the client's bladder using Crede's maneuver - no need for this
A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? a. Length from head to heel of 40 cm (15.7 in) b. Bulging fontanels c. Chest circumference 2 cm (0.8 in) smaller than the head circumference d. Nasal flaring
c. Chest circumference 2 cm (0.8 in) smaller than the head circumference a. Length from head to heel of 40 cm (15.7 in) - 45-55 cm (18-22 in) b. Bulging fontanels - indicate inc ICP, infection, hemorrhage c. Chest circumference 2 cm (0.8 in) smaller than the head circumference d. Nasal flaring - respiratory distress *Something extra: newborn weight: 5.5 - 8 lbs (normal)
A nurse is reviewing a client's rubella titer of 1:8 at her second prenatal visit. Which of the following statements by the nurse is appropriate? a. Because rubella is a live vaccine you will not be able to breastfeed your newborn b. Your titer indicates you are susceptible to rubella c. During your third trimester you will need to repeat blood test for the titer d. You will need a rubella immunization at your next prenatal visit
c. During your third trimester you will need to repeat blood test for the titer a. Because rubella is a live vaccine you will not be able to breastfeed your newborn- (it is not communicable in breast milk. However the virus is shed in urine and other body fluids so it should not be given to other members who are immunocompromised.) b. Your titer indicates you are susceptible to rubella- if <1:8 c. During your third trimester you will need to repeat blood test for the titer d. You will need a rubella immunization at your next prenatal visit - contraindicated for pregnancy
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Creatinine 0.9 mg/dL b. WBC count 11,000/mm c. Fasting blood glucose 180 mg/dL d. Hematocrit 35%
c. Fasting blood glucose 180 mg/dL a. Creatinine 0.9 mg/dL - normal 0.5-1.1 b. WBC count 11,000/mm - normal 4.5-11k c. Fasting blood glucose 180 mg/dL - possible gestational diabetes! (Norm: Less than 100) d. Hematocrit 35% - normal 34-44%
A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heartbeat. Which of the following terms should the nurse use to document this finding? a. Goodell's sign b. Quickening c. Funic souffle d. Hegar's sign
c. Funic souffle a. Goodell's sign - probable sign - softening of cervical tip b. Quickening - presumptive sign - slight fluttering movements of the fetus felt by the woman (between 16- 20 weeks of gestation) c. Funic souffle- Lowdermilk PDF PG. 293 (sound made by blood rushing through the umbilical vessels and synchronous with the fetal heart rate). d. Hegar's sign - probable sign - softening and compressibility of the lower uterus
A charge nurse is discussing STIs with a newly licensed nurse. Which of the following infections should the nurse include in the teaching as an indication for a cesarean birth a. Gonorrhea b. Chlamydia c. HIV d. Syphilis
c. HIV a. Gonorrhea- spread genital to genital b. Chlamydia c. HIV - cesarean birth at 38 weeks for maternal viral load of >1,000 copies/mL - infant should be bathed after birth before remaining with the mother d. Syphilis *C-section-malpresentation, breech, non reassuring heart tones, placenta previa, abruptio placentae, HIV, preeclampsia, DM, genital herpes, umbilical cord prolapse
A nurse is reviewing the medication prescriptions for a newborn who is 6 hr. old and whose mother is HBsAg-positive. The nurse should anticipate administering which of the following medications? a. Hep A vaccine b. Haemophilus influenzae type B vaccine c. Hep B immune globulin d. Hep A immune globulin
c. Hep B immune globulin a. Hep A vaccine b. Haemophilus influenzae type B vaccine c. Hep B immune globulin- (newborn born to infected mothers should receive hep B vaccine and the hepatitis B immune globulin within 12 hours after birth) d. Hep A immune globulin
A nurse is teaching a client who is postpartum about car seat safety. Which of the following statements indicates an understanding of the instructions? a. I will adjust the angle of the car seat so that my baby is at a 90 degree angle b. I will position the car seat in the front passenger seat facing the front of the car c. I will place the shoulder harness slightly below my baby's shoulders d. I will make sure the retainer clip is at the level of my baby's abdomen
c. I will place the shoulder harness slightly below my baby's shoulders a. I will adjust the angle of the car seat so that my baby is at a 90 degree angle (45) b. I will position the car seat in the front passenger seat facing the front of the car - back passenger, rear facing c. I will place the shoulder harness slightly below my baby's shoulders d. I will make sure the retainer clip is at the level of my baby's abdomen (armpit)
A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? a. Apply suprapubic pressure b. Administer a diuretic to the client c. Insert an indwelling urinary catheter d. Encourage the client to void in the shower
c. Insert an indwelling urinary catheter ATI pg 122
A nurse is caring for a client who is at 35 weeks of gestation and on bed rest due to severe preeclampsia. Which of the following is an appropriate action for the nurse to take? a. Maintain NPO status b. Obtain BP every 8 hr c. Keep the lights dimmed in the room d. Auscultate fetal heart tones twice per day
c. Keep the lights dimmed in the room - to prevent stimulation of seizures
A nurse is calculating the estimated date of birth using Nagele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year? a. March 14 b. March 21 c. March 28 d. April 4
c. March 28 ATI pg 15: Take the first day of the woman's last menstrual cycle, subtract 3 months, and then add 7 days and 1 year, adjusting for the year as necessary. Nicole's way - take the date of the last menstrual cycle add 7 days then add 9 months and wala the est. date!
A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care? a. Wash the circumcision site with mild soap and water 24 hr following the procedure b. Take off the plastic bell 2 hr after the procedure c. Monitor for bleeding every 15 min for the first hour d. Remove the yellow drainage on the 2nd postoperative day
c. Monitor for bleeding every 15 min for the first hour a. Wash the circumcision site with mild soap and water 24 hr following the procedure -sponge bath around area NOT on it! b. Take off the plastic bell 2 hr after the procedure - if falls off in 5-7 days c. Monitor for bleeding every 15 min for the first hour d. Remove the yellow drainage on the 2nd postoperative day - don't remove (ATI pg.178) postprocedure assess for bleeding every 15-30 min for the first hour and then hourly for the next 4-6 hours
A nurse is discussing family planning with a client who has a history of DVT. The nurse should inform the client that this condition is a contraindication for which of the following birth control methods? a. Intrauterine device b. Cervical cap c. Oral contraceptive d. Diaphragm
c. Oral contraceptive a. Intrauterine device b. Cervical cap c. Oral contraceptive d. Diaphragm ATI OB PG. 7 DISADVANTAGES: Women with HX of blood clots, stroke, cardiac problems, breast or estrogen-related cancers, pregnancy, or smoking (if over 35 years of age- advised NOT to take Oral contra.
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication a. BP 136/88 mmHg b. Urinary output 120 ml in 2 hrs. c. Respiratory rate 10 min d. Moderate fetal heart rate variability
c. Respiratory rate 10 min a. BP 136/88 mmHg (hypotension not HTN) b. Urinary output 120 ml in 2 hrs. c. Respiratory rate 10 min d. Moderate fetal heart rate variability - decreased FHR variability (another test chose this answer) ATI OB 135 Butorphanol (Stadol) provide pain relief without causing significant respiratory depression in the mother or fetus. ATI OB 146 Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that are irregular in frequency and amplitude. Classification of variability: 1) Minimal V. (greater than undetectable but less than 5/min). 2) Moderate V. (6 to 25/min). 3) Marked V. (greater than 25/min) ATI Pharm 431: A/E: Tachycardia, hypotension, and decreased FHR variability.
A nurse is a caring for a client who is at 24 weeks of gestation and has a glucose screening test result of 150 mg/dL. Which of the following actions should the nurse take? a. Perform a urine screen for ketones b. Repeat the glucose screening test in 15mins to verify results c. Schedule the client for a 3 hour oral glucose tolerance test d. Determine if the client has fasted
c. Schedule the client for a 3 hour oral glucose tolerance test a. Perform a urine screen for ketones b. Repeat the glucose screening test in 15mins to verify results c. Schedule the client for a 3 hour oral glucose tolerance test d. Determine if the client has fasted ATI OB 98 A glucose screening test/1-hr glucose tolerance test (50 g oral glucose load, followed by plasma glucose analysis 1 hr. later performed at 24-48 weeks of gestation- fasting not necessary; a positive blood glucose screening is 130-140 mg/dl or greater; additional testing within a 3-hr. oral glucose test (OGTT) is indicated.
A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? a. The newborn's respiratory rate is 32/min b. The newborn's pulse ox is 91% c. The newborn is beginning to cough d. The newborn's respiratory rate is irregular
c. The newborn is beginning to cough a. The newborn's respiratory rate is 32/min (normal RR 30-60) b. The newborn's pulse ox is 91% c. The newborn is beginning to cough d. The newborn's respiratory rate is irregular - breathing is irregular and shallow, can have periods of apnea, no longer than 20 seconds.
A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory test used to evaluate this condition? a. Liver enzymes b. Complete blood count c. Urine ketones d. Thyroid levels
c. Urine ketones - and acetone - due to breakdown of protein and fat - most important initial lab test ATI pg 58
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood glucose 110mg/dL b. DTR of 2+ c. Urine protein of 3+ d. Hemoglobin 13 g/dL
c. Urine protein of 3+ a. Blood glucose 110mg/dL b. DTR of 2+ c. Urine protein of 3+ (severe preeclampsia proteinuria > 3) d. Hemoglobin 13 g/dL Severe preeclampsia: proteinuria >3 - can lead to ECLAMPSIA (with seizures)
A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? a. Place an ice pack on the newborn's heel 5 min before the procedure b. Cleanse the newborn's heel with an alcohol swab after the procedure c. Use an automatic puncture device on the heel d. Puncture the heel on the inner aspect of the foot
c. Use an automatic puncture device on the heel a. Place an ice pack on the newborn's heel 5 min before the procedure - warm to inc. circulation b. Cleanse the newborn's heel with an alcohol swab after the procedure - cleanse before the procedure c. Use an automatic puncture device on the heel d. Puncture the heel on the inner aspect of the foot -outer aspect of the heel should be used
A nurse is assessing the results of a nonstress test for an antepartal client at 35 wks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing? a. Three fetal movements perceived by the client in a 20 min testing period b. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration w/in a 10 min testing period c. Irregular contractions of 10-20 secs in duration that are not felt by the client d. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40 min testing period
d. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40 min testing period a. Three fetal movements perceived by the client in a 20 min testing period b. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration w/in a 10 min testing period c. Irregular contractions of 10-20 secs in duration that are not felt by the client d. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40 min testing period Interpreted as reactive if FHR is a ● normal baseline rate with moderate variability ● accelerates to 15 beats/min for AT LEAST 15 SECONDS and ● occurs TWO or more times during a 20 MINUTE PERIOD Nonreactive if it doesn't meet criteria after 40 min p. 52 ATI
A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching? a. Wear nipple shields during the feeding b. Use a breast binder for 2 days c. Use plastic-lined breast pads d. Apply cabbage leaves after feedings
d. Apply cabbage leaves after feedings ATI pg. 129 Cold compresses (15 min on and 45 min off) - after feeding. Fresh, cold cabbage leaves can be placed inside the bra. Warm compresses/warm shower beforefeeding to stimulate the drop down effect
A nurse is assessing a client who is in her second trimester for common physiological changes during pregnancy. The nurse notes a blotchy discoloration on the client's forehead, nose & cheeks. Which of the following changes should the nurse document a. Linea nigra b. Epulis c. Striae gravidarum d. Chloasma
d. Chloasma a. Linea nigra -(dark line pigmentation from umbilicus to the pubic area.) b. Epulis - (not found on ati book, but it is a tumor on the mouth caused by gingervitis.) c. Striae gravidarum - (stretch marks found on abdomen and thigh) d. Chloasma -( increase pigmentation on the face)
A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following findings indicates narcotic withdrawal? a. Respiratory rate 50/min b. Unequal pupils c. Hypotonia d. Excessive crying
d. Excessive crying Substance withdrawal in the newborn occurs when the mother uses drugs during pregnancy. Hitch pitch shrill cries, incessant crying, tremors, increased deep tendon reflexes, disturbed sleep pattern, hypertonicity, convulsions
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Proteinuria b. Hyperemesis c. Hypoxia d. Hemorrhage
d. Hemorrhage May be performed after 14 weeks of gestation ○ Complications: amniotic fluid emboli, maternal/fetal hemorrhage, fetomaternal hemorrhage w/ Rh isoimmunization, maternal/fetal infection, inadvertent fetal damage or anomalies involving limbs, fetal death, inadvertent maternal intestinal/bladder damage, miscarriage or preterm labor, premature rupture of membranes, leakage of amniotic fluid
A nurse is teaching a prenatal client about listeriosis and dietary medications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. I can still have a hotdog at the ballpark b. I can purchase a seafood salad from the grocery store c. I can have a midday snack with soft cheese d. I can eat grilled chicken on a bun at lunch time
d. I can eat grilled chicken on a bun at lunch time a. I can still have a hotdog at the ballpark b. I can purchase a seafood salad from the grocery store- should not be eaten c. I can have a midday snack with soft cheese d. I can eat grilled chicken on a bun at lunch time Lowdermilk pg 321 "during pregnancy, women should not consume unpasteurized milk or products made with unpasteurized milk, including soft cheeses. Hotdogs, luncheon meats, bologna, and deli meats should be eaten only if they have been reheated to be steaming hot Listeriosis - eating food contaminated with Listeria bacteria
A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse should anticipate which of the following tests to assess for fetal lung maturity? a. Direct Coombs' test b. Biophysical profile c. Chorionic villus sampling (CVS) d. Lecithin/sphingomyelin ratio
d. Lecithin/sphingomyelin ratio a. Direct Coombs' test b. Biophysical profile c. Chorionic villus sampling (CVS) d. Lecithin/sphingomyelin ratio ATI OB PG. 56 A LSR 2:1 ratio indicating fetal lung maturity (2:5:1 or 3:1 for a client who has diabetes mellitus.
A nurse is assessing a client who is 1 hr postpartum. The nurse notes a large amount of vaginal bleeding with several large blood clots on the client's peripad. The clients bp is 70/42 mmHg and her heart rate is 150/min. Which of the following actions should the nurse take first? a. Apply O2 at 10-12 L/min b. Elevate the legs c. Administer an IV bolus of oxytocin d. Massage the fundus
d. Massage the fundus a. Apply O2 at 10-12 L/min- (#3 priority-- Provide oxygen at 2 to 3 L/min per nasal cannula) b. Elevate the legs- (#4 priority-- Elevate legs to a 20° to 30° angle to increase venous return) c. Administer an IV bolus of oxytocin- (#2 priority-- To promote uterine contraction, a faster action than massaging the fundus) d. Massage the fundus (#1 priority--PDF p.136: Firmly massage the uterine fundus to promote uterine contractions. Uterine atony causes pooling of blood leading to postpartum hemorrhage (blood clots larger than a quarter; perineal pad saturation in 15 min or less; constant oozing, trickling, or frank flow of bright red blood from the vagina; tachycardia and hypotension)
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? a. Lay the tape measure horizontally over the middle of the client's abdomen b. Place the client in a left-lateral position to obtain the measurement c. Ensure that the client has a full bladder before taking the measurement d. Measure from the upper border of the symphysis pubis to the upper border of the fundus.
d. Measure from the upper border of the symphysis pubis to the upper border of the fundus. ATI pg 15
A nurse in a prenatal clinic is reviewing the lab results for a client who is 12 wks gestation. Which of the following actions should the nurse take a. Administer rubella b. Obtain a maternal serum alfa fetoprotein specimen c. Administer ceftriaxone IM d. Obtain a blood culture
d. Obtain a blood culture a. Administer rubella b. Obtain a maternal serum alfa fetoprotein specimen c. Administer ceftriaxone IM d. Obtain a blood culture Rationale: PG. 19. At 12 weeks is the start of prenatal visit. You need to check blood for titers, vaccines, and blood levels
A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy? a. Check the newborn's identification using the crib card. b. Replace the infant's identification band after his name has been recorded. c. Require visitors to wear an identification band. d. Obtain an imprint of the infant's feet prior to taking him to the nursery.
d. Obtain an imprint of the infant's feet prior to taking him to the nursery. a. Check the newborn's identification using the crib card. (Verify Wrist/ankle band w/ mom's ID band) b. Replace the infant's identification band after his name has been recorded. c. Require visitors to wear an identification band. (Mom & dad) d. Obtain an imprint of the infant's feet prior to taking him to the nursery. ATI p. 164: Identification band: Newborn's name, sex, date, time of birth, and mother's health record number. Newborn, mother, and mother's partner - must have identification wristbands Newborn's footprints and mother's thumb prints are taken
A nurse is providing prenatal teaching to a group of clients who are in their trimester of pregnancy. Which of the following statements by a client indicates an understanding of the teaching? a. I should lie on my back as much as possible during the labor process b. I will be allowed to start to push once my cervix is dilated to 5 cm c. Once my water has broken, I will not be able to have epidural anesthesia d. Panting will help me control the urge to push when my cervix is not completely dilated
d. Panting will help me control the urge to push when my cervix is not completely dilated a. I should lie on my back as much as possible during the labor process -(PDF p.80: 4 stages of labor = all with different non-pharmacological interventions for pain) (causes supine hypotension) b. I will be allowed to start to push once my cervix is dilated to 5 cm (PDF p.73: wait for complete dilation of 10cm) c. Once my water has broken, I will not be able to have epidural anesthesia (PDF p.82: Administered when the client is in active labor and dilated to at least 4 cm) d. Panting will help me control the urge to push when my cervix is not completely dilated - (PDF p.110:Encourage the client to pant with an open mouth between contractions to control the urge to push)
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. Hemoglobin 14.8 g/dL b. Urine protein concentration 200 mg/24 hr c. Creatinine 0.8 mg/dL d. Platelet count 60,000/mm
d. Platelet count 60,000/mm a. Hemoglobin 14.8 g/dL b. Urine protein concentration 200 mg/24 hr (normal: <80 mg/24 hr) c. Creatinine 0.8 mg/dL d. Platelet count 60,000/mm HELLP syndrome - variant of gestational hypertension - coexist with severe preeclampsia H - hemolysis (anemia and jaundice) EL - elevated liver enzymes LP - low platelets (<100,000) - can lead to DIC
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Incompetent cervix b. Ectopic pregnancy c. Hyperemesis gravidarum d. Postpartum hemorrhage
d. Postpartum hemorrhage a. Incompetent cervix b. Ectopic pregnancy (X abnormal implantation of ovum outside uterine cavity) c. Hyperemesis gravidarum (X excessive N/V) d. Postpartum hemorrhage (happens when labor is too long not quickly) Rationale: Since labor is happening quickly patient is risk for hemorrhage. If you have cervical insufficiency (sometimes called incompetent cervix), it means that your cervix has started to efface and dilate too soon. This can cause you to give birth too early
A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client. a. Intense contractions lasting 45-60 seconds b. An urge to have a bowel movement during contractions c. A sense of excitement and warm, flushed skin d. Progressive sacral discomfort during contractions
d. Progressive sacral discomfort during contractions a. Intense contractions lasting 45-60 seconds - active phase - normal b. An urge to have a bowel movement during contractions - transition phase - baby about to come out!! c. A sense of excitement and warm, flushed skin - latent phase? d. Progressive sacral discomfort during contractions
A nurse is assessing a newborn who is 2 hrs. old. Which of the following findings should the nurse report to the provider? a. Lanugo on the pinna of the ears b. Overlapping the sutures with molding c. Transient nystagmus d. Single transverse palmar crease bilaterally
d. Single transverse palmar crease bilaterally a. Lanugo on the pinna of the ears - normal b. Overlapping the sutures with molding - normal due to head compression c. Transient nystagmus d. Single transverse palmar crease bilaterally - indicative of fetal alcohol syndrome
A charge nurse is teaching newly licensed nursing about fetal monitoring. The newly licensed nurse should identify that which of following images indicates prolonged decelerations?
see picture
