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ATI MATERNAL NEWBORN TEST COMPILATION BUNDLE
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ATI- Maternal Newborn Final Questions and Answers 2023
A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the us... [Show More] e of this device? Mennorhagia A nurse is reinforcing teaching with a client with a client who is pregnant. Which of the following instructions should the nurse include? "You should use floride-based toothpaste to prevent dental caries." A nurse is assisting with the plan of care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? At 28 weeks of gestation A nurse is caring for a newborn who was born to a client who was a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? Frequent stimulation A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? Group B Streptococcus B-hemolytic culture A nurse is assisting in the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? Ensure the newborn's eyes are closed before applying the eye shield A nurse is caring or a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the nurse's priority? "My heart feels as if it is racing." A nurse is assisting with caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following should the nurse identify as the priority? Nonreactive nonstress test A nurse is caring for a newborn who was irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? Continue to routinely monitor the newborn A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the nurse include in the teaching as a nutrient for the client to increase the intake of while breastfeeding? Vitamin C A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Nagele's rule, which of the following is the client's expected date of birth (EDB)? April 15 A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with severe clots. Which of the following actions should the nurse take first? Massage the fundus A nurse is reinforcing discharge instructions with a client following the removal of a hydatiform mole. Which of the following statements should the nurse include in the teaching? "Do not become pregnant for at least 1 year." A nurse is preparing a client who is pregnant for an ultrasound. Which of the following information is the most important for the nurse to collect? The time of the client's last void A nurse is reinforcing teaching with a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? "I should press the button on the hand held marker when my baby moves." A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions should the nurse take? Initiate a latex free environment A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following information should the nurse include? "Your baby should have bursts of 15 sucks or swallows at a time." A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan? "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." A nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for the use of this medication? Active genital herpes A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the emergency was announced several weeks ago. Which of the following responses should the nurse make? "These feelings are common for expectant fathers in early pregnancy." A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching? "You will have a cesarean birth prior to the onset of labor." A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? A 12-hour-old newborn who has a heart rate of 70/min while sleeping A nurse is assisting with the care of a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? Retinopathy A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? "I will warm the bottle of formula by placing it in a pan of hot water." A nurse is collecting data for a newborn who is 12 hr old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take/ Obtain a stat prescription for a bilirubin level A nurse is caring for four newborns. Which of the following newborns is a greatest risk for hypoglycemia? A newborn who is large for gestational age A nurse administers betamethasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When assisting with care for the newborn. Which of the following conditions should the nurse identify as an adverse effect of this medication? Decreased blood glucose A nurse is collecting data on a client who is at 8 weeks of gestation. Which of the following findings should the nurse report to the provider? Small amount of brown vaginal discharge A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron IM. Which of the following methods should the nurse use to administer the medication? Use a 20-gauge needle, and administer the medication using the Z-track method A nurse is caring for a client who is at 8 weeks of gestation with twins and is primigravida. The client states that even though she and her planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make? "These feelings are normal at the beginning of pregnancy." A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? "A weight gain of about 25 to 35 pounds is good." A nurse is caring for a newborn who has a neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? Exaggerated reflexes A nurse is contributing to the plan of care for a client who plans to formula feed her newborn. Which of the following actions should the nurse include in the plan? Have the client place ice packs on her breasts four times per day A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? "I should replace my diaphragm every 2 years." A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I became very sissy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take? Instruct the client about vena cava syndrome and measures to prevent it [Show Less]
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ATI Maternal/Newborn Questions and Answers 2023
Acronym for pregnant woman: GTPAL - gravida - term (38-42 weeks) - preterm (... [Show More] y: 20 weeks gestation What is the rule used to determine gestational age: Nagele's rule - subtract 3 months and add 7 days and a year Serum levels and hCG test: - hCG can increase in production as early as the day of implantation and can be detected 7-10 days after conception - hCG levels reach peak at 60-70 days gestation and begin to decline after 80 days - high levels of hCG may mean ectopic pregnancy, multifetal pregnancy, or chromosomal problems such as Downs - low levels of hCG likely mean a miscarriage Ectopic pregnancy: - when ovum implants into the fallopian tubes of abdominal cavity because endometrial tissue is present - if the ovum begins to grow in the fallopian tube, it can lead to a rupture of the fallopian tubes --> fatal hemorrhage - client will report of severe shoulder pain associated with ruptured ectopic pregnancy due to presence of blood in abdominal cavity - unilateral stabbing pain in lower-abdominal quadrant - can give client Methadextrone to stop the production of cells, can also surgically remove ovum supine hypotensive syndrome: can occur when a pregnant woman is in the supine position and an the fetus in the uterus is pressing against her inferior vena cava. - encourage woman to roll onto her left side or go into semi-fowler's position What does it mean when accelerations are noticed in FHR it means that their CNS is intact - accelerations are a good thing Prenatal visit frequency: - monthly for first 7 months - every 2 weeks for the 8th month - then every week for last months Fetal HR can be heard by a _______ device from weeks (?-?) and it can be heard by a _________ at week (?-?) - Doppler device at weeks 10-12 - ultrasound stethoscope around weeks 16-20 When will you apply RhoGAM - administer RhoGAM at 28 weeks to moms who are Rh-, also can administer to mothers after delivery, should be within 72 hours How much H2O should a pregnant woman consume? - 2-3 liters daily Feelings of _______ can occur during pregnancy but should resolve around_______ - ambivalence (mixed feelings) - should resolve by 3rd trimester First trimester: Second trimester: Third trimester: - week 1-12 - week 13-27 - week 28-birth During third trimester mother should count fetal movement for? - at least 2-3 times a day for 60 minutes - less than 3 fetal movements in 60 minutes means that there should be further assessment UTIs during pregnancy: UTIs are very common during pregnancy due to vaginal flora becoming more alkaline, which makes it easier for bacteria to grow, usually caused by e-coli How to help with back pain: - encourage mother to do pelvic rock exercises to help strengthen back muscles, also nurse can provide pressure on lower sacral region. During second trimester, mothers should increase their caloric intake by: - should eat an extra 340 cal/day During the third trimester, mothers should increase their caloric intake by: - should eat an extra 452 cal/day During breastfeeding mothers should increase their caloric intake by: - should increase caloric intake by 330 cal/day During pregnancy mothers should also increase their intake in: - protein: essential to basic growth - folic acid: helps with infants neurologic development and helps prevent against fetal neural defects - iron is also recommended and should be taken with Vit. C (helps with absorption), calcium and caffeine make it harder for iron to be absorbed - calcium intake should be 1000mg/day Caffeine should be limited to? 300 mg/day - too much caffeine can increase the risk for spontaneous abortions Vegetarians are usually low in: - protein, vit. B 12, iron, zinc, and calcium Low iron: - can lead to anemia - look for signs of pica: a condition where the person craves non-food items (chewing ice, eating chalk, laundry soap or dirt) Excessive weight gain can lead to: macrosomia and labor complications Maternal Phenylketonuria (PKU) - a genetic disorder in which mother has high levels of phenylalanie and it poses a danger to the fetus - put mother on PKU diet - stay away from foods high in protein (fish, beans, meat, eggs, and dairy products) Woman who are breastfeeding should increase their intake of? - calories by 330 cal - iron (avoid drinking caffeine because can interfere with infants ability to absorb caffeine) - protein - oral fluids - get an adequate amount of calcium Weight gain expected during trimesters: - first trimester: 3-4 ibs - second trimester and third: 1 ibs/week - weight gain for normal BMI: 25-35 ibs External Ultrasound: - done during the first trimester - it is noninvasive - does require a full bladder for best results - want the uterus to be displaced Transvaginal ultrasound: - invasive procedure - done during 3rd trimester - gives a more accurate reading - does not require bladder to be full - helpful for obese patients - want client in lithotomy position Biophysical profile: - looks at the physical and physiological characteristics of the fetus - FHR - breathing movements - gross body movements - fetal tone - amniotic fluid - give 2 pts each - the higher the score the better - low score can mean fetal asphyxia Non-stress test (NST): - checks accelerations - monitors FHR in response to fetal movement - Doppler transducer to monitor FHR - tocotransducer to monitor maternal uterine contractions - mother will have button she will press every time she fells the baby moving - here we check to see if fetal CNS is in tact - REACTIVE test is when there are accelerations for 15 seconds 15bpm and occurs 2+ times during 20 minute period - NONREACTIVE test is when FHR does not accelerate adequately with fetal movements What can the nurse do if there is no fetal movement? nurse can use viroacoustic stimulation to try to wake the fetus up (not above 90 decibles and only for 3 seconds) Contraction Stress Test (CST): - looks at declarations - analyze the FHR response to uterine contractions determines how the fetus will tolerate stress during labor - want 3 contractions in a span of 10 minutes that last 40-60 seconds Nipple stimulated CST: mother will roll her nipple between her fingers to stimulate the release of oxytocin from the anterior pituitary gland, when oxytocin is released, it causes the uterus to contract hyperstimulation of uterus: - when uterine contraction lasts longer than 90 seconds and more frequent than 2/min, can administer tocolytics to slow down contractions and the progression of labor oxytocin stimulate CST: when contractions start with the administration of oxytocin (pitocin) - may be difficult to stop - may lead in preterm labor - need to monitor contractions very closely - CST neg. CST is normal (3 uterine contractions within 10 minutes, no late decels) + CST positive CST is abnormal (late decels on more than half of the contractions) Variable decels can mean: - cord compression Early decels can mean: - head compression Prolonged decels: - decels lasting longer than 90 seconds, these are the most concerning What should you administer in the event of uterine hyperstimulation: - tocolytics Amniocentesis: - aspiration of amniotic fluid for analysis by insertion of needle through the abdominal wall into the uterus and the amniotic sac - can ONLY BE DONE after 14 weeks gestation AFP: - can be measured from the amniotic fluid between 16-18 weeks and may be used to assess for neural tube defects - high levels: neural tube defect, spina bifida - low levels: chromosomal disorder, downs syndrome Lung Maturity: - Lecithin/sphingomyelin: want a 2:1 ratio - want + phosphatidylglycerol (you want it to be present, because an absence is associated with respiratory distress - can administer betamethadone to help with surfactant production --> lung maturity Percutaneous Umbilical Blood Sampling (PUBS) - obtains fetal blood from the umbilical cord Chorionic Villus Sampling (CVS) - assessment of chorionic villus from the developing placental wall - can do this test at 10-12 weeks gestation First trimester bleeding: - spontaneous abortion - ectopic pregnancy Second trimester bleeding: gestational trophoblastic disease - uterine size increases at an alarming rate - abnormally large amount to hCG - scant or profuse dark brown or red vag. blood Third trimester bleeding: - placenta previa - abruptio placenta Spontaneous abortion: - when pregnancy is terminated before 20 weeks of gestation or if fetal weight is less than 500g - 50% of spontaneous abortions are caused by chromosomal abnormalities Types of spontaneous abortions: - threatened: moderate spotting and cervical opening closed - inevitable: moderate cramps, mild/severe bleeding, cervix dilated, membranes or tissue protruding - incomplete: severe cramps, bleeding, partial fetal tissue expulsion, some still left in cervical canal - complete: all tissue expelled, minimal bleeding, mild cramps, cervical opening is closed - missed: no cramps, brownish discharge, no tissue passed, opening is closed - septic: usually dilated cervix and sometimes tissue passed - reccurent: tissue passed, sometimes cramps, bleeding and usually dilated. Dilation and Cureltage: - D & C - when a provider will go in a manually scrape out tissue in vaginal canal, usually used for incomplete or inevitable abortions Dilation and Evaluations: - used to scape out uterine contents after 16 weeks gestation Gestational Trophoblastic Disease: - molar pregnancy - it is the proliferation and degradation of trophoblastic villi that will become swollen, fluid-filled and take on a grape like cluster shape - these structures are associated with choriocarcinoma (rapidly metastasizing malignancy) - rapid uterine growth - excessive nausea and vomiting due to increased hCG levels - preeclampsia before 24 weeks gestation - scant, dark, discharge occurs in 2nd trimester Placenta previa: - this is when the placenta appears at the cervical opening before the fetal presenting part - mother will be advised to remain bed rest Abruptio Placenta: - premature separation of the placenta from the uterine wall - separation occurs after 20 weeks gestation What drug is administered to promote lung maturity? Betamethasome (Celestone) - administer 2 injections, 24 hours apart - requires a 24 hours period for it to become effective - helps with fetal lung maturity and hastens surfactant production HIV/AIDS: - a retrovirus that destroys T-lymphocytes - can be transmited perinatally through the placenta or even through breast milk - when detected early providers can administer retrovir (zidovudine): antiretroviral agent - instruct client not to breastfeed [Show Less]
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ATI Maternal Newborn: Assessment A & B (2023) Questions and Answers
2020 Assessment A with a few review questions ... A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Whic... [Show More] h of the following statements by the parent indicates an understanding of the teaching? A. "Some assistive personnel might not have name badges." B. "A nurse will carry my baby back to the nursery in their arms for routine care when it is needed." C. "I will ask the nurse to take my baby back to the nursery if I need to leave my room." D. "I can remove my baby's security band before giving her a bath." "I will ask the nurse to take my baby back to the nursery if I need to leave my room." A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following? A. Facilitate the storage of iron in the fetus' liver B. Prevent certain kinds of birth defects C. Inhibit premature labor D. Aid in the absorption of other important nutrients Prevent certain kinds of birth defects A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy. Which of the following laboratory values should the nurse recognize as an indication that the therapy has been effective? A. Glucose 45 mg/dL B. WBC count 10,000/mm3 C. Total bilirubin 5 mg/dL D. Hgb 16 g/Dl Total bilirubin 5 mg/dL A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider? (select all that apply) A. Acrocyanosis B. Tachypnea C. Nasal flaring D. Retractions E. Expiratory grunting 1. Tachypnea 2. Nasal flaring 3. Retractions 4. Expiratory Grunting A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? A. Begin giving approximately 240 mL (8 oz) per feeding after the first week B. Position the bottle at a 45 angle during feedings C. Ensure that the newborn empties the bottle D. Wait to burp the newborn until the end of the feeding Position the bottle at a 45 angle during feedings A nurse is collecting data from a client who is in the second trimester of pregnancy. Which of the following findings should the nurse report to the provider? A. Increased leukorrhea B. Hyperpigmentation of the face C. Varicose veins D. Frequent uterine contractions Frequent uterine contractions A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? A. Vernix in the skin folds B. Positive Moro reflex C. Apneic episode of 10 seconds D. Apical heart rate of 90/min while crying Apical heart rate of 90/min while crying A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? A. 1 cup dried prunes B. 1/2 cup boiled potatoes C. 1/2 cup dried peas D. 1 cup grapes 1/2 cup dried peas A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity? (select all that apply) A. Hyperreflexia B. Decreased respiratory rate C. Polyuria D. Decreased level of consciousness E. Double vision 1. Decreased respiratory rate 2. Decreased level of consciousness 3. Double vision A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? A. Leg cramps B. Tingling of fingers C. Varicose veins D. Epigastric pain epigastric pain *manifestation of preeclampsia A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching? A. "The diaphragm should be removed 2 hours after having intercourse." B. "I can use water-soluble lubricant when my partner wears a latex condom." C. "It is ok for me to remove the birth control sponge within 2 hours after having intercourse." D. "When I use the birth control patch, it must be changed once a month." "I can use water-soluble lubricant when my partner wears a latex condom." A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? A. Intramuscular B. Intradermal C. Subcutaneous D. Topical Subcutaneous *every 4 hours. relaxes the smooth muscles and inhibits uterine activity A nurse is observing a client bather her 1 day old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe the newborn? A. The client shakes powder from the container onto the newborn's skin B. The client uses a cotton-tipped swab to clean the newborn's ears C. The clients washes the newborn's hair before unwrapping them D. The client rinses the newborn under warm, running water The clients washes the newborn's hair before unwrapping them A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Place the client in high-Fowler's position B. Administer terbutaline subcutaneously C. Apply oxygen at 2 L/min via nasal cannula D. Insert an indwelling catheter insert an indwelling catheter *to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete? A. Apgar score B. Newborn Hearing Screen C. Critical Congenital Heart Disease screen (CCHD) D. Neonatal Abstinence Scoring System Neonatal Abstinence Scoring System A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome? A. Negative rubella titer B. Reactive stress test C. 1 hour glucose tolerance screening test result of 150 mg/dL D. Hemoglobin 9.5 g/dL Reactive stress test A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? A. Maternal newborn temperature of 37.5 C (99.5 F) B. Contractions every 3 min C. Presence of bloody show D. Prolonged deceleration of FHR Prolonged deceleration of FHR A nurse is a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take? A. Instruct the client to avoid crowds until a repeat hepatitis B test is negative B. Tell the client that they will need to start the hepatitis B vaccine series after birth C. Explain to the client that they will receive the hepatitis B immune globulin immediately D. Inform the client that hepatitis B cannot be transmitted to the fetus Explain to the client that they will receive the hepatitis B immune globulin immediately [Show Less]
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ATI Maternal Newborn Dynamic Quizzes Questions and Answers 2023
A nurse is assessing a client who is 14 hr postpartum and has a third-degree her new laceration. The clients temperature is 37.8°C (100°F), and her fundu... [Show More] s is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? Assist the client to empty her bladders a nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take? Stop the oxytocin infusion A nurse is assessing a 12-hour old newborn notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? Obtain a stat prescription for bilirubin level A nurse is caring for a client in the third trimester of pregnancy who reports difficulty sleeping. Which of the following instructions should the nurse provide? Use additional pillows to support extremities and abdomen A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take? Continue to monitor the fetal heart tracing. A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assess the client? Lateral A nurse is providing teaching for a client at seven weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse and understanding of the teaching? I should have a small snack before bedtime A nurse is assessing a client who is at 36 weeks of gestation which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? Double vision A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder the nurse should notify the provider about which of the following assessment findings? The client reports a frequent cough A nurse is caring for a client who is in labor the client speaks a different language than the nurse and he's been missing. Which of the following actions should the nurse take while waiting for an interpreter? Change the clients position A nurse is providing teaching for a client who is pregnant and has type one diabetes mellitus. Which of the following statements should the nurse include in the teaching? You should expect to decrease your insulin dosage immediately after you deliver your baby A nurse is caring for a client in labor and observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take? Document the findings and continue to monitor A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? IV narcotics administered to the mother during labor A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? Hypotension A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching? Before bedtime is a good time to start counting the kicks A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? Intracranial hemorrhage A nurse is caring for a newborn who has neonatal abstinence syndrome which of the following Clinical findings should the nurse expect? Exaggerated reflexes A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following intervention should the nurse include? Assist the client into a warm shower A nurse is providing teaching to a client who has come to the family planning clinic requesting an intrauterine device IUD. Which of the following pieces of information should the nurse provide to the client? Your risk for ectopic pregnancy increases with an IUD A nurse is teaching a client who is pregnant and has pre-gestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? Carbohydrates should make up 55% of your diet A provider does a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggest eating more meat after the provider leaves the examination room the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? Let's discuss other foods that are also high in protein that you can substitute for meat A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal position should the nurse document in the medical record? Vertex A nurse is teaching a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? These exercises should be done for 15 minutes each day to strengthen the peroneal muscles A nurse is providing care to a client who is 12 hours postpartum and is receiving oxytocin IV. The client asked the nurse, why is there so little bleeding? Which of the following responses should the nurse make? The bleeding is minimal until I discontinue your IV medication A nurse is planning care for a Client who is post partum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? Monitor the clients weights weekly A nurse is caring for a client who is at 35 weeks of gestation and he scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? You will feel so much discomfort during this procedure A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? 3+ deep tendon reflexes A nurse is providing teaching about exercise for a client who is pregnant which of the following pieces of information should the nurse include? Vigorous exercise it should be limited and should not be performed in hot humid weather [Show Less]
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ATI maternal Newborn Retake Questions and Answers 2023
1. A nurse is assessing newborn following forceps assisted birth. Which of the following clinical manifestations should the nurse identify as a complicati... [Show More] on of the birth method? A. Hypoglycemia B. Polycythemia C. Facial Palsy D. Bronchopulmonary dysplasia C Which of the following statements by client indicates an understanding of the teaching? A. "The medication could cause me to experience heart palpitations" B. "This medication could cause me to experience blurred vision" C. "This medication could cause me to experience ringing in my ears" D. "This medication could cause me to experience frequent ..." A A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate? A. Urine Ketones B. Rapid plasma regains C. Prothrombin time D. Urine culture A A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort? (SATA) A. Assisting the client into squatting position B. Having the client lie in a supine position C. Applying fundal pressure during contractions D. Encouraging the client to void every 6 hr A D A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect? A. Thick, White Vaginal Discharge B. Urinary Frequency C. Vulva Lesions D. Malodorous Discharge D A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above the umbilicus D. Lateral at the Xiphoid Process A 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. Urine protein contraction 200mg/24 hours B. Creatine 0.8 C. Hemoglobin 14.8 D. Platelet 60,000 D A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include? A. Tinnitus B. Urinary Frequency C. Breast Tenderness D. Chills C (vision disturbances). A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect? A. Bulging fontanelles B. Nasal flaring C. Length from head to heel of 40cm D. Chest circumference 2c (smaller than the head circumference D A nurse is planning care for a newborn who has necrotizing abstinence syndrome. Which of the following interventions should the nurse include in the plan of care? A.Increase the newborn visual stimulation B. Weigh the newborn everyday C. Discourage parental interaction after a social evaluation D. Swaddle the newborn in a flexed position D A nurse is caring for a newborn who his 6 hours old had has a bedside glucometer reading of 65mg/dl. The newborns mother has type 2 diabetes mellitus. Which of the following actions should the nurse take. A. obtain a blood sampling for a serum glucose level. B. Feed the newborn immediately C. Administer 50ml of dextrose D. Reassess the blood glucose reading prior to the next feeding D A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the folioing statements by the client indicates an understanding of the teaching (SATA)? A. I will limit my time in the hot tub to 30 miniutes after exercise B. I should consume three 8 ounce glasses of water after I exercise C. I will check my heart rate every 15 minutes during D. I should limit exercise sessions to 30 minutes when the weather is humid E. I should rest by lying on my side for 10 minutes following exercise. B D E A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider? A. Contractions duration 95 seconds to 100 seconds B. Contraction frequency 2-3 minutes C. Absent early decelerations of fetal heart rate C A nurse in a woman's health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client's risk for developing pelvic inflammatory disease (PID)? A. Recurrent Cystitis B. Frequent Alcohol Use C. Use of Oral Contraceptives D. Chlamydia Infection D A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching? A. Hepatitis B B. Rotavirus C. Pneumococcal D. Varicella A A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. ½ cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli D 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. December 15 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 expels the placenta B. The client experiences gradual dilation of the cervix C. The client begins have regular contractions. D. The client delivers the newborn D [Show Less]
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Maternal newborn ati proctored exam Questions and Answers 2023
A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What meds should the nurse plan to administer? a. misoprostol... [Show More] b. betamethasone c. poractant alfa d. methylergonovine b. betamethasone A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will be used to confirm her pregnancy? a. urine test for presence of HCG b. urine test for the presence of HCS c. blood test for presence of estrogen d. blood test for the amount of circulating progesterone a. urine test for presence of HCG A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? a. palpable fetal movement b. amenorrhea c. chadwick's sign d. positive pregnancy test a. palpable fetal movement A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect? a. renal agenesis b. atrial septal defect c. spina bifida d. hydrocephalus a. renal agenesis A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic fracture due to blunt abd trauma. What findings should the nurse expect? a. uterine contractions b. bradycardia c. seizures d. bradypnea a. uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma. A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings should the nurse expect? a. hypothermia b. dark brown vaginal discharge c. fetal heart tones d. decreased urinary output b. dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters. A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority? a. 480 mL urine output in 24 hrs b. 1+ protein in the urine c. +2 edema of the feet d. BP 144/92 a. 480 mL urine output in 24 hrs When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding. A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse include in the teaching? a. you will be in isolation after delivery b. abstain from sexual intercourse throughout pregnancy c. breastfeed your newborn to provide passive immunity d. you should continue to take zidovudine throughout the pregnancy d. you should continue to take zidovudine throughout the pregnancy -can be transmitted through breastfeeding -she can continue to have sex The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn. A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to report to the provider during pregnancy. What info should the nurse include in the teaching? a. nausea upon awakening b. blurred or double vision c. increase in white vaginal discharge d. leg cramps when sleeping b. blurred or double vision A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take? a. decrease the dose of oxytocin by half b. administer oxygen via nonrebreather mask c. decrease the infusion rate of the maintenance IV fluid d. administer terbutaline 0.25mg subq a. decrease the dose of oxytocin by half The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole. A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take? a. prepare the client for emergency c-section b. perform endotrach suctioning as soon as the fetal head is delivered c. prepare equipment needed for newborn resuscitation d. prepare the client for an ultrasound exam c. prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery. A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider? a. insert a large-bore IV catheter b. perform a vaginal exam c. perform continuous external fetal monitoring d. obtain a blood sample for lab testing b. perform a vaginal exam When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding. A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What action should the nurse take? a. request a script for an internal fetal scalp electrode b. auscultate the FHR with a doppler transducer c. report the nonreactive test result to the provider immediately d. use vibroacoustic stim on the client's abd for 3 seconds d. use vibroacoustic stim on the client's abd for 3 seconds The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR. A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take? a. instruct the client to obtain a rubella immunization after delivery b. request a script for an antibiotic until delivery c. inform the client that she will have to deliver via c-section d. administer a dose of Pho(D) immune globulin a. instruct the client to obtain a rubella immunization after delivery A nurse is reviewing the med record of a client who is at 39 wks gestation and has polyhydramnios. What finding should the nurse expect? a. total pregnancy wt gain of 3.6 kg b. fetal GI anomaly c. gestational HTN d. fundal height of 34 cm b. fetal GI anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios. A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. What adverse effects should the nurse include in the teaching? a. elevated BP b. feeling of warmth c. generalized pruritis d. hyperactivity b. feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing. A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. What action should the nurse take? a. position the client supine with legs elevated b. instruct the client to pant during contractions c. encourage the client to soak in a warm bath d. apply pressure to the client's sacral area during contractions d. apply pressure to the client's sacral area during contractions A nurse is teaching a client who is at 12 wks gestation about manifestations of potential complications that she should report to her provider. What info should the nurse include in the teaching? a. intermittent nausea b. white vaginal discharge c. swelling of the face d. urinary frequency c. swelling of the face A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in the first trimester. What info should the nurse include in the teaching? a. you will need to have a full bladder during the ultrasound b. you will have a non stress test prior to the ultrasound c. the ultrasound will determine the length of your cervix d. you will experience uterine cramping during the ultrasound a. you will need to have a full bladder during the ultrasound MY ANSWER The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus. A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect? a. decreased urinary output b. fetal distress c. dark red vaginal bleeding d. increased platelet count c. dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding. A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule, the nurse should identify the client's estimated DOB as what? a. oct 15 b. april 15 c. oct 1 d. april 1 b. april 15 A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of late decels? a. umbilical cord compression b. fetal head compression c. uteroplacental insufficiency d. fetal ventricular septal defect c. uteroplacental insufficiency A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the provider? a. DTR 2+ b. resp 16 c. BP 150/96 d. urinary output 20 mL/hr d. urinary output 20 mL/hr The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia. A nurse is teaching a client who is at 13 wks gestation about the treatment of incompetent cervix with cervical cerclage. What statement by the client indicates an understanding of teaching? a. I should go to the hospital if I think I may be in labor b. I should expect bright red bleeding while the cerclage is in place c. I am sad that I won't be able to get pregnant again d. I can resume having sex as soon as I feel up to it a. I should go to the hospital if I think I may be in labor Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy. A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. What action should the nurse take? a. obtain blood samples for baseline lab values b. place a spiral electrode on the fetal presenting part c. prepare the client for a transvaginal ultrasound d. perform a vaginal exam to determine cervical dilation a. obtain blood samples for baseline lab values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels. A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. What action should the nurse take? a. auscultate for a FHR b. reassure the client that a term fetus is less active c. have the client drink orange juice d. palpate the uterus for fetal movement a. auscultate for a FHR Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action. A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia. What assessment provides the most accurate info regarding the client's fluid and electrolyte status. a. daily wt b. bp c. severity of edema d. I&O a. daily wt A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching? a. 10 fetal movements per hour b. mild constipation c. vaginal bleeding d. nasal congestion c. vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor. A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What info should the nurse include? a. you will have to undergo a c-section birth because of the fibroid b. the fibroid can increase the risk for postpartum hemorrhage c. the fibroid will shrink during pregnancy d. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid b. the fibroid can increase the risk for postpartum hemorrhage A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate? a. you should drink 1 ounce of mineral oil q morning b. you should eat at least 3 ounces of red meat/day c. you should walk for at least 30 minutes q day d. you should stop taking your prenatal c. you should walk for at least 30 minutes q day The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal region b. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings c. use photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective. A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings b. place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment a. place the newborn directly on the client's chest the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature. A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm c. I will place my baby on his back when it is time for him to sleep [Show Less]
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ATI Maternal newborn 2 Questions and Answers 2023
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a... [Show More] . check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings b. place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding. A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment a. place the newborn directly on the client's chest The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal region b. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings c. use photometer to monitor the lamp's energy the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm c. I will place my baby on his back when it is time for him to sleep The newborn should always sleep on his back to prevent sudden infant death syndrome. A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7 b. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis. A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder d. assist the client to empty her bladder When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia. A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer? 0.25 A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion a. continue routine monitoring the nurse should continue routine monitoring because the newborn's assessment findings indicate he is adapting to extrauterine life A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway d. assist the client to ambulate in the hallway walking can help stimulate peristalsis, which will promote expulsion of gas A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect? a. heel creases covering the bottom of the feet b. good flexion c. abundant lanugo d. dry, parchment-like skin c. abundant lanugo Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead. [Show Less]
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RN Maternal Newborn Online Practice 2023 B – ATI Questions and Answers
A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of th... [Show More] e following findings should the nurse instruct the client to notify the provider? Shortness of breath A. Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? Leakage of fluid from the vagina B. Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? Answer: September 3rd A. September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd. A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? Answer: Biophysical profile (BPP) C. Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? Answer: "You can share your room with your baby for the next few weeks." A. "You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? Answer: Apply sacral counterpressure. A. Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Answer: Cover the newborn's eyes while under the phototherapy light. A. Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? Answer: Apply internal upward pressure to the presenting part using two gloved fingers. B. Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand. A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (SATA) Answer: Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? Answer: "Staff members who take care of your baby will be wearing a photo identification badge." D. "Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs. A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Answer: Vomiting D. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Answer: Vomiting A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? Answer: Left lower quadrant A. Left upper quadrant The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. B. Right upper quadrant The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. C. Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. D. Right lower quadrant The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant. A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? Answer: Stop suctioning when the newborn's cry sounds clear. D. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? Answer: Platelets 50,000/mm3 D. Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta? A. The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area. Answer: A A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? Answer: A client who is at 34 weeks of gestation and reports epigastric pain B. A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicated an understanding of the teaching? Answer: "I will eat foods that taste good instead of balancing my meals." A. "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Answer: Demonstrate to the client how to perform a newborn bath. D. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment. A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? Answer: Swelling of the face A. Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? Answer: Jitteriness A. Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? Answer: "I will have blood tests because my potassium might decrease." A. "I will get injections of the medication once daily until my labor stops." Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. B. "My blood sugar may be low while I'm on this medication." An adverse effect of terbutaline is hyperglycemia. C. "I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia. D. "My blood pressure may increase while I'm on this medication." An adverse effect of terbutaline is hypotension. A nurse is planning care for a client who is in labor and is having an amniotomy. Which of the following assessments should the nurse identify as the priority? Answer: Temperature B. Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions should the nurse include in the plan of care for lactation suppression? Answer: Apply cabbage leaves to the breasts. B. Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? Answer: Determine respiratory function. A. Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? Answer: "I will continue taking my insulin if I experience nausea and vomiting." C. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Answer: Chin quivering B. Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interperate the client's statement as an indication of which of the following? Answer: Emotional lability A. Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives? (SATA) Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives. A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? Answer: "You should take the medication within 72 hours following unprotected sexual intercourse." A. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? Answer: Place the retainer clip at the level of the newborn's armpits. B. Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? Answer: The nurse should have calcium gluconate readily available B. Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head. A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? Answer: Headache that is unrelieved by analgesia C. Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? Answer: Massage the client's fundus. A. Massage the client's fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? Answer: Just above the symphysis pubis B. Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? Answer: "You will be offered orange juice to drink during the test." C. "You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results. A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? Answer: Instruct the client to press the provided button each time fetal movement is detected. D. Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? Answer: "You can miss your period for several other reasons. Describe your typical menstrual cycle." A. "You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. [Show Less]
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Maternal Newborn ATI B retake Questions and Answers 2023
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina after calling for assist... [Show More] ance which of the following actions should the nurse take next Apply internal upward pressure to the presenting part using two gloved fingers A nurse is planning care for a client who is two hours postpartum which of the following intervention should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment Demonstrate to the client how to perform a newborn bath A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test which of the following statements should the nurse include in the teaching You will be offered orange juice to drink during a test A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is it eight weeks of gestation the nurse should instruct the client to increase her daily intake of which of the following nutrients Iron A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa which of the following actions should the nurse take Initiate continuous external fetal monitoring A nurse is assessing fetal heart tones for a client who is pregnant the nurse is determined the fetal position as left occipital anterior to which of the following areas of the clients abdomen sure the nurse apply the ultrasound transducer to assess the point of maximum intensity to the fetal heart Left lower quadrant A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture the prescription states administer is it from ice in 1 g Orly now available is 250 mg tablets how many tablets for the nurse administer round the answer to the nearest whole number using leading zero if it applies do not use a trailing zero 4 tablets A nurse is caring for a newborn who is undergoing photo therapy to treat hyperbilirubinemia which of the following actions should the nurse take Cover the newborns eyes while under the photo therapy light A school nurse is providing teaching to an adolescent about levonorgestrel contraception which of the following information should the nurse include in the teaching You should take the medication within 72 hours following unprotected sexual intercourse A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm which of the following statement should the nurse include in the teaching You should leave the diaphragm in place for at least six hours after intercourse A nurse is caring for a client who is at 22 weeks of gestation and reports concern about blotchy hyperpigmentation on her forehead which of the following actions should the nurse take Explain to the client that this is an expected occurrence A nurse is teaching a client who is in preterm labor about terbutaline which of the following statements by the client indicates an understanding of the teaching I will have blood tests because my potassium might decrease A nurse is assessing a newborn of a client who took a selective serotonin reuptake inhibitor during pregnancy which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI Vomiting A nurse is assessing a newborn who is 12 hours old which of the following manifestations require interventions by the nurse Substernal chest retractions while sleeping A nurse in the antepartum clinic is assessing a client adaptation of pregnancy the client states that she is happy one minute and crying the next the nurse should interpret the clients statement as an indication of which of the following Emotional lability A nurse on a antepartum unit is caring for four clients which of the following client to the nurse identify as a priority A client who is at 34 weeks of gestation and reports epigastric pain A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit which of the following findings should the nurse report to the provider Swelling of the face A nurse is providing discharge teaching to a client who has postpartum for which of the following manifestation should the nurse instruct the client to monitor and report to the provider Unilateral breast pain A nurse is teaching a new mother how to use a bulb syringe to suction her newborn secretions which of the following instructions should the nurse include Stop suctioning when the newborns cry sound clear A nurse is reviewing laboratory results of a newborn who is four hours old which of the following findings should the nurse report to the provider Bilirubin of 9 mg/dL A nurse in a family planning clinic is caring for a client who request an oral contraceptive which of the following findings in the clients history to the nurse recognizes a contraindication to oral contraceptives select all that apply Cholecystitis Hypertension Migraine headaches A nurse is teaching a postpartum Kline about the steps the nurses will take to promote the security and safety of the clients newborn which of the following statement should the nurse make Staff member to take care of your baby will be wearing a photo identification badge A nurse is reviewing the laboratory results for a client who is at 10 weeks gestation which of the following laboratory findings should the nurse report to the provider Hemoglobin 10 g/dL A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV which of the following actions should the nurse take Have calcium gluconate readily available A nurse is caring for a client who is in active labor and has no cervical change in the last four hours which of the following statement should the nurse make Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions A nurse is caring for a newborn who was transferred to the nursery 30 minutes after birth because of mild respiratory distress which of the following actions should the nurse take Verify the newborns identification [Show Less]
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ATI Maternal/Newborn Questions and Answers 2023
The nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which action should the nurse take? Apply pressure... [Show More] tothe client's sacral area during contractions. "The nurse should provide counter pressure to the sacral area with a palm or firm object, like a tennis ball, during cxs. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain." A nurse is caring for a client who is at 32 wks of gestation and is experiencing preterm labor. Which of the following meds should the nurse plan to administer? Bethmethasone "Administering bethmethasone IM, a gluccocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression." A nurse is caring for a client who has oligohydraminos. Which fetal anomaly should the nurse expect? Renal agenesis "Oligohydraminos is a volume of amniotic fluid <300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydraminos." A nurse is caring for a client at 39 wks gestation in the active phase of labor. The nurse observes late decels in the FHR. Which of the following findings should the nurse identify as the cause? Uteroplacental insufficiency "A late decel in the FHR is a nonreassuring pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should preposition the client, initiate O2, and increase the infusion rate of IV fluid to enhance placental perfusion" A nurse is caring for a client whose last menstrual period began July 8. Using Negele's rule, the nurse should identify the pts estimated date of birth (EDB) as which of the following? April 15th "Using Negele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days" The nurse is caring for a pt at 35 wks gestation and has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? Daily weight "EBP indicates that daily weight is the most accurate assessment to determine a client's F&E status." A nurse is reviewing the medical record of pt who is at 33 wks gest. and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? Perform a vaginal examination When a client has placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical OS (the opening to the vagina). The nurse should clarify this order bc any manipulation can cause tearing of the placenta and increased bleeding." A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which action should the nurse take first? Obtain blood samples for baseline laboratory values. "The nurse should obtain samples of the pts blood for baseline testing of HgB and Hct levels" A nurse is providing teaching to a client at 8 wks gestation about manifestations to report to the provider during pregnancy. Which information should she include in the teaching? Blurred or double vision "The pt should report blurred or double vision as these could be a manifestation of gestational HTN or pre-eclampsia" A nurse is caring for a pt who believes she may be pregnant. Which of the following findings should the nurse identify as a POSITIVE sign of pregnancy? Palpable fetal movement "Palpable fetal mvmts are a positive sign of pregnancy. Quickening, the client's report of fetal mvmt is a presumptive sign of pregnancy." Chawick's sign and a positive pregnancy test are only probable signs of pregnancy, and amenorrhea is a presumptive sign of pregnancy bc she can have that from many other things. Nurse is caring for a pt at 38 wks gestation who reports no fetal mvmt for 24 hrs. Which action should the nurse take? Auscultate for a fetal heart rate "Presence of a FHR is a reassuring manifestation of fetal well-being. The nurse should auscultate using a doppler or an external fetal monitor. A nurse is teaching a pt at 12 wks gestation and has HIV. What should the nurse include in the teaching? You should continue to take zidovudine throughout the pregnancy. "The nurse hsould inform the client that taking the prescription antiviral medication everyday decreases the risk of transmission of HIV to her newborn" The nurse is teaching a pt at 12 wks gestation about the manifestations of potential complications that she should report to the provider. Which information should the nurse include in the teaching? Swelling of the face "Instruct the pt to report swelling of the face bc this can indicate a HTN disorder or preeclampsia." A nurse is teaching a client at 10 wks gestation about an abdominal ultrasound in the first trimester. Which info should the nurse include in the teaching? You will need to have a full bladder during the ultrasound. "A full bladder helps lift the gravid uterus out of the pelvis during the exam. It is important the pt have a full bladder to obtain the most accurate image of the fetus." When and why is a nonstress test preformed? After 26 weeks gestation to determine fetal well being What kind of ultrasound measures cervical length? When and why is this exam preformed? A transvaginal ultrasound measures cervical length in the second and third trimester to assess for preterm labor A pt at 37 weeks gestation is undergoing a nonstress test. The FHR is 130/min without accelerations for the past 10 minutes. Which action should the nurse take? Use vibroacoustic stimulation on the pts abdomen for 3 seconds. "Use of a vibroacoustic stimulator on the client's abdomen elicits fetal activity bc the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR." When is a nonstress test considered nonreactive? After 40 minutes of continuous monitoring without accelerations in the FHR despite vibroacoustic stimulation A nurse is assessing a pt whos at 35 wks gestation and receiving mag sulfate via continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider? Urinary output of 20 mL/hr "This can indicate inadequate renal perfusion,increasing th erisk for mag sulfate toxicity. A decrease in UO can also indicate a decrease in renal perfusion ST a worsening of the pts preeclampsia." Should a pt at 30 weeks gestation report vaginal bleeding to her provider? Yes. IY can indicate a complication such as placental abruption, placental previa, or preterm labor. A nurse is assessing a pt at 37 wks gest. who has a suspected pelvic fracture due to a blunt abdominal trauma. What should the nurse expect? Uterine contractions. "The nurse should expect the client to have uterine cxs due to abdominal trauma" A nurse is teaching a pt at 13 wks gest. about treatment of incompetent cervix with cervical cerclage. Which statement by the pt indicates understanding? I should go to the hospital if I think I'm in labor. "Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation is she expereinces any labor manifestations while the cerclage is in place. If she experiences preterm uterine cxs she might need tocolytic therapy." The nurse is reviewing the labs for a pt at 37 wks gest. She notes that the clinet is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type of type O negative. Which action should the nurse take? Instruct the pt to get a rubella immunization after delivery. (she will receive ABX DURING labor to prevent transmission of GBS to the newborn) The nurse is reviewing the record of a pt at 39 wks gest who has polyhydraminos. Which finding should the nurse expect? Fetal GI anomaly "Polyhydraminos is the presence of excessive amniotic fluid surrounding the unborn fetus. GI malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydraminos" What is a cause of oligohydraminos? gestational HTN The nurse is assessing a pt at 34 weeks gest. and has mild placental abruption. What should the nurse expect? Dark red vaginal bleeding A pt with preeclampsia is going to receive mag sulfate through continuous IV infusion. What expected adverse effects should the nurse include in teaching? Feeling of warmth all over the body while mag sulfate is infusing (non adverse effects: decreased BP, feeling of sedation) The nurse is caring for a pt in active labor who has meconium staining of the amniotic fluid. The FHR is reassuring. What action should the nurse take? Prepare equipment needed for newborn resuscitation. "The nurse should ensure that all equipment needed for resuscitation is available for early delivery. Endotracheal suctioning is recommended in cases of meconium staining ONLY if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery." A nurse is assessing a client who is at 35 wks gestation and has preeclampsia without severe features. Which finding should the nurse identify as the priority? 480 mL UO in 24 hrs. "The minimum accepted UO for an adult is 30 mL/hr. This can indicate progression of preeclampsia with severe features, requiring immediate intervention." A pt in the latent phase of labor is receiving oxytocin via cont. IV infusion. She is having cxs every 2 mins which last for 100-110 seconds, and the FHR is reassuring. Which action should the nurse take? Decrease the dose of oxytocin by half. "The nurse should reduce the oxytocin by half because the pt is experiencing uterine tachysystole" A client reports intestinal gas pain after a cesarean section. What should the nurse do? Assist her to ambulate in the hallway "Walking helps stimulate peristalsis which promotes expulsion of gas" The nurse is caring for a newborn who is premature in the NICU. Which action should the nurse take to promote development? Position naked newborn on the parent's bare chest. "Doing this decreases stress in the parent and newborn. This can help maintain thermal stability, raise O2 saturations, increase feeding strength, and promote breastfeeding" A nurse is providing teaching to a PP woman who does not plan to breastfeed her newborn. What instructions should the nurse give? Place icepacks on your breasts. "place ice packs on her breasts using a 15 min on 45 min off schedule to decrease swelling as the body produces milk" A nurse is planning care for a client who is PP with cardiac disease. Which order should the nurse seek clarification on? A. Monitor the pts I & Os B. Initiate a high-fiber diet for the pt C. Monitor the pts weight weekly D. Initiate bedrest with the HOB elevated C. Monitor the client's weight weekly. "the client's weight should be monitored daily for fluid overload" [Show Less]
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