VATI RN Maternal Newborn Assessment
A nurse is monitoring the laboratory results for a client who has preeclampsia with severe features. Which of the following results should the nurse expect?
Increased BUN.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse identify as an indication of a prenatal complication?
BUN 30 mg/dL
A nurse is assessing a client who is 6hrs postpartum, tachycardia, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?
Initiate and infusion of oxytocin.
A nurse is creating a plan of care for a client who is at 35wks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following interventions should the nurse include?
Initiate continuous monitoring of the FHR.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor?
International normalized ratio (INR).
A nurse is providing teaching about nifedipine for a client who is at 34wks of gestation and has gestational HTN. For which of the following adverse effects should the nurse instruct the client to notify the provider?
Irregular heartbeat.
A nurse is preparing to administer an opioid analgesic to a client who is in active labor. Which of the following assessments should the nurse perform? (SATA)
Maternal blood pressure. Pain level. Fetal heart rate.
A nurse is caring for a 2 day old newborn who has a bilirubin level of 14 mg/dL and is to begin phototherapy. Which of the following actions should the nurse take?
Monitor intake and output.
A nurse is monitoring a client who is in the active phase of labor and has an intrauterine pressure catheter and fetal scalp electrode. Which of the following findings should the nurse expect?
Montevideo units (MVU) of 220 mm Hg.
A nurse is monitoring a client who is receiving oxytocin to augment labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following actions is the nurse's priority?
Position the client laterally.
A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. Which of the following actions should the nurse take?
Position the client using the McRoberts maneuver.
A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?
Respiratory rate 12/min
A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of the following findings should the nurse identify as a risk factor for developing preeclampsia?
Rheumatoid Arthritis.
A nurse is caring for a newborn immediately following birth who has meconium-stained amniotic fluid and exhibits good muscle tone and respiratory efforts. Which of the following actions should the nurse take first?
Begin suctioning of mouth and nose.
A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the nurse include in the teaching?
Bring your newborn in the bassinet into the bathroom with you.
A nurse is monitoring a client who is in active labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following findings should the nurse recognize as the potential cause of the deceleration?
Fetal hypoxia
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad in 15min. The clients skin is cool and clammy to touch. Which of the following actions should the nurse take first?
Firmly massage the fundus.
A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the provider?
Generalized petechiae
A nurse is reviewing the laboratory report of a term newborn who is 24hrs old. Which of the following laboratory results should the nurse report to the provider?
Glucose 35 mg/dL.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse report to the provider?
Hct 31%
A nurse is assessing a newborn following a circumcision 48hrs ago. The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?
Healing.
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?
Heart rate 54/min
A nurse is caring for a client who is at 28wks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?
Heart rate: 132/min
A nurse is collecting information about a health history for a client who requests a prescription for a combined oral contraceptive (COC). Which of the following information should the nurse identify as a contraindication for the use of a COC?
History of migraine with aura.
A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?
Hypotonia
A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching?
I can breastfeed my baby even though I received this immunization.
A nurse is interviewing a client who is at 10wks of gestation. Which of the following statements by the client should the nurse investigate further?
I just want to stay in bed all day because nothing interest me anymore.
A nurse is providing prenatal education to a client who is at 16wks of gestation. Which of the following statements by the client indicated an understanding of anticipated body changes during the second trimester?
I might notice a change in my skin coloring.
A nurse is teaching a new guardian how to correctly use a car seat. Which of the following statements by the guardian indicates an understanding of the teaching?
I should keep my baby in a rear-facing car seat until he is 2yrs old.
A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching?
I will be certain to consume 29 grams of fiber daily.
A nurse is performing an initial assessment during a client's first prenatal visit. The client states that her last menstrual period began April 22. Use Nagele's rule to calculate the expected date of birth (EDB).
0129
A nurse is caring for a newborn who was delivered by cesarean birth 1 min ago and displays some flexion of the extremities, is not cry, has irregular respiratory effort, and has a heart rate of 92/min. The nurse notes grimacing but no crying when rubbing the soles of the newborn's feet. The newborn's skin color is pink with blue extremities. What is the correct Apgar score?
1 min is 5.
A nurse is teaching a class to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (SATA)
1. Management of postpartum pain 2. Advantage of early ambulation post-surgical procedure. 3. The need for an indwelling urinary catheter during delivery.
A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the nurse should take to clear the airway obstruction.
1. Stand posterior to the client. 2. Position arms under the client's axilla and across the client's chest. 3. Place thumb-side of a clenched fist to the client's mid-sternum area. 4. Initiate chest thrust to the client using a backward motion. -If the client becomes unconscious, the nurse should perform CPR and activate emergency medical services.
A nurse is assessing a client who is at 8wks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (SATA)
1. Tachycardia. 2. Dry mucous membranes. 3. Poor skin turgor.
A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the following statements should the nurse include in the teaching? (SATA)
1. You might have to have cultures for sexually transmitted infections prior to placement of the device. 2. You might experience irregular spotting the first few months after placement of the device. 3. You will need to sign informed consent prior to the procedure.
A nurse is preparing to administer methotrexate 1 mg/kg IM to a client who weights 110lbs and is receiving care for an ectopic pregnancy. Available is methotrexate 25 mg/mL. How many mL should the nurse administer?
2
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the following statements should the charge nurse make?
A chancre lesion appears within 90 day after infection during the primary stage.
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?
A client who has an indwelling urinary catheter.
A nurse is caring for a client who had a vaginal delivery 2hrs ago and is reporting increasing perineal pain and pressure. The nurse examines the clients perineum and sees a 4cm (1.6in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following?
A hematoma
A nurse is receiving report on four newborns born in the past 12hrs. Which of the following newborns should the nurse assess first?
A newborn who has an axillary temperature of 36C (96.8F).
A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36wks of gestation. Which of the following actions should the nurse expect to take?
Administer IV antibiotic prophylaxis.
A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take?
Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is 10/min. Which of the following actions should the nurse take first?
Administer oxygen by nonrebreather face mask.
A nurse is performing a contraction stress test (CST) on a client who is at 40wks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take?
Allow the labor to progress naturally.
A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?
Amenorrhea.
A nurse is caring for a postpartum client who is breastfeeding her newborn and reports that her nipples have become sore and cracked. Which of the following statements should the nurse make?
Apply colostrum to the nipples after feeding to help them heal.
A nurse is providing teaching for a client who is 2wks postpartum and has mastitis. Which of the following instructions should the nurse include in the teaching?
Apply moist heat to the affected breast.
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level in the abdomen a nurse should expect to find the client's uterus when assessing the fundus.
C is correct. -Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum.
A nurse is caring for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following actions should the nurse plan to take?
Change the newborn's position every 2hrs.
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my baby is breech." Which of the following actions should the nurse take first?
Check fetal heart tones.
A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?
Cleanse the puncture site with alcohol gauze prior to the procedure.
A nurse is teaching a client who has hyperemesis gravidarum about dietary modifications. Which of the following client statements indicates an understanding of the teaching?
I will eat small, frequent meals throughout the day.
A nurse is teaching routine prenatal care to a group of clients who are pregnant. Which of the following statements by a client indicates an understanding of the teaching?
I will have monthly prenatal visits for the first 28wks of pregnancy.
A nurse is providing teaching for a guardian regarding newborn care. Which of the following statements by the guardian indicates understanding of the teaching?
I will use a rear-facing car seat for my baby for the first 2 years.
A nurse is planning to use a Doppler device to auscultate fetal heart tones (FHTs) for a client who is at 12wks of gestation. Which of the following actions should the nurse plan to take?
Count the radial pulse of the client while auscultating FHTs.
A nurse is assessing a newborn who was born 15mins ago. Which of the following actions should the nurse take?
Count the respiratory rate for 60 seconds.
A nurse is assessing a client who is in labor, Which of the following findings should the nurse expect?
Decrease in blood glucose level.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following findings is an indication the medication was effective?
Decreased frequency of contractions.
A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48hrs after birth. Which of the following findings should the nurse report to the provider?
Depressed fontanels.
A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
Encourage client who are prescribed methadone to breastfeed.
A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?
Encourage the client to listen to music
A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the clients pain?
Encourage the support person to apply sacral counterpressure.
A nurse is assessing a client who is at 32wks of gestation. Which of the following findings is an indication of a potential prenatal complication?
Epigastric pain.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse report to the provider?
Epigastric pain.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse report to the provider?
Episodes of blurred vision.
A nurse is reviewing the results of a nonstress test for a client who is at 37wks of gestation. Which of the following findings indicates a reactive nonstress test?
Fetal heart rate (FHR) accelerations occur with fetal movement.
A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take?
Obtain a vaginal culture.
A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect?
Painless vaginal bleeding.
A nurse is assessing a newborn who was born 15min ago and has an axillary temperature of 36.1C (97F). Which of the following actions should the nurse take?
Place the newborn skin to skin on the mother's chest.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching regarding situations requiring an amniotomy?
Placing a fetal scalp electrode.
A nurse is reviewing the laboratory report of a client who is at 31wks of gestation and has gestation hypertension. Which of the following laboratory results should the nurse report to the provider?
Platelet count 99,000/mm3.
A nurse is providing teaching to a client who is at 8wks of gestation about vaccines that are administered during pregnancy. Which of the following vaccines should the nurse discuss with the client?
Tetanus-diphtheira-acellular pertussis (Tdap) vaccine.
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?
The most accurate indication of organ perfusion is a clients urine output.
A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching?
The patent should plan to spend individual time with the older sibling.
A nurse is caring for a client who is in active labor and receiving epidural anesthesia. The client reports feeling nauseated and experiences a blood pressure drop from 125/70 mm Hg to 90/50 mm Hg. Which of the following actions should the nurse take first?
Turn the client to a lateral position.
A nurse is assessing a client who has genital herpes. Which of the following findings should the nurse expect?
Ulcerated lesions on the labia.
A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due to a postpartum hemorrhage. Which of the following findings is the best indication of adequate perfusion and oxygenation?
Urinary output.
A nurse is preparing to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?
Warm the newborn's heel for 10mins prior to the puncture.
A nurse is providing discharge instructions to the parents of a newborn about bathing. Which of the following statements by the parent indicates an understanding of the instructions?
We will wash out newborn's face first.
A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. Which of the following actions should the nurse take?
Wear two pairs of gloves when handling the medication.
