ATI PN PROCTORED MATERNAL NEWBORN WITH NGN
A nurse is assessing a newborn who was bornat26 weeks of gestation using the New Ballard Score. Which of
the... [Show More] following findings should the nurse expect?
Minim alarm recoil
- The nurse should expect a newborn who was born at26 weeks gestation to have decreased
muscular tone,or minim alarm recoil.
A nurse is assessing a newborn following circumcision. Whichof the following findings should the nurse identify
as an indication that the newborn is experiencing pain?
Chinquivering
- Behavioral responses to a newborn’s pain include facial expressions (ex:chinquivering,
grimacing, & furrowing of the brow).
A nurse is assessing the new born of a client who took a selective serotonin re uptake inhibitor (SSRI)
during pregnancy. Which of the following manifestations should the nurse identify as an indication of
withdrawal from an SSRI?
Vomiting
- Expectedclinical manifestations associated withfetalexposureto SSRIs includeirritability,
agitation, tremors,diarrhea, & vomiting.Theseusually last2days.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia.
Whichof thefollowingactionsshouldthenurseincludein theplan?
Removeallclothingfrom thenewbornexcept thediaper.
- The nurse should remove all of the newborn’s clothing except the diaper while under
phototherapy. Maximum skinexposuretotheultraviolet light isneededtobreakdown the excess
bilirubin.
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic
culturalbeliefs.Whichof the followingculturalpractices should thenurse include in the plan of care?
Protect theclient’s headandfeet from coldair.
- Protecting the client’s head and feet from cold air should be included in the planof care because
this is a traditional Hispanic practice during the postpartum period. Hispanicpractices also
includedelayingbathingfor 14days,bedrest for3 days,anddrinking warm beverages following
delivery.
A nurse is caringforaclient whois at 38 weeks of gestation. Whichof thefollowingactions should the
nurse take prior to applying an external transducer for fetal monitoring?
Perform Leopold maneuvers.
- Thenurseshould perform Leopold maneuvers toassess thepositionof thefetusto best
determine the optimal placement for the external fetal monitoring transducer.
A nurse is caringforaclient whois inactive laborandhas hadnocervicalchangein thelast4hours.
Whichof the followingstatements should the nurse make?
Yourprovider will insertanintrauterinepressurecatheter to monitor thestrengthof yourcontractions.
- Insertionofanintrauterinepressurecatheter isnecessarytodetermineuterinecontraction
intensity, which will identify whether or not the contractions are adequatefor the progression
of labor.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. Afternotifying
theprovider, whichof thefollowingactions should thenursetakenext?
Massagetheclient’s fundus.
- Thegreatest risk totheclient is hemorrhage.Therefore, thenextactionthe nurseshould take is
to massage the client’s fundus to expel clots and promote contractions.
A nurse is reviewing the medical record of a client who is one day postpartum. Theclient had a
vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider
regarding whichof the followingprescriptions?
Bisacodyl rectalsuppositorydailyasneededforconstipation
- Thenurseshouldnotadministera rectalsuppositoryorenemato aclient whohas a fourthdegree perineal laceration. These can cause separation of the suture line, bleeding, or
infection.
A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurseenters the room
andobserves theclienthaving aseizure. After turningthe client’s headto one side, which of the following
actions should the nurse take immediately after the seizure?
Administeroxygenvia anonrebreather mask.
- Whenusingtheairway,breathing,andcirculationapproachtoclientcare, thenurse should
place the priority on administering oxygen to the client via a nonrebreather masktoensure
adequateoxygenationto motherandfetus.
A nurse inaprenatalclinic is caringforaclient whoreports thather menstrualperiod is2 weeks late.
The client appears anxious and asks the nurse if she is pregnant. Which of the following responses
should the nurse make?
”Youcan miss yourperiodforseveralother reasons. Describeyour typical menstrualcycle”.
- Amenorrheaisapresumptivesignofpregnancy,notapositivesign.Therefore,the nurse
should explore the client’s menstrual cycle to determine other necessaryinterventions.
A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for
gestational diabetes mellitus. Which of the following instructions should the nurse include in the
teaching?
”Youshouldgeta2-houroralglucosetolerancetest in 6-12 weeks.”
- Thenurseshould instruct theclient toget2-houroralglucosetolerancetest 6-12weeks
postpartum and every 3 years to screen for type 2 diabetes. The nurse should instruct the client
that blood glucose levels return to the expected reference range after childbirth. Therefore, the
client does not need to monitor herblood glucose levels orcontinue the insulin at home.
A nurseonanantepartum unit is caringfor4clients. Whichof thefollowingclientsshouldthe nurse
identifyas thepriority?
A client who isat 34 weeks gestationandreports epigastric pain
- Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement,
which is anurgent finding.Therefore, thenurseshouldidentifythisclientas the priority.
A nurse onthepostpartum unit is caringforaclient followinga cesareanbirth. Whichofthefollowing
assessments is the nurse’s priority?
Amountof lochia
- Whenusingtheairway,breathing,circulationapproach toclientcare, thenurseshould place
the priority in the immediate postpartum period on assessing the amount of postpartum
lochia. The greatest risk to the client is bleeding and postpartum hemorrhage.
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 thefollowing actions should
the nurse take?
Applysacralcounterpressure
- Sacralcounterpressureassists inrelievingback laborpainrelatedto fetalposterior
position.
A nurse is demonstrating toaclienthow tobathehernewborn. In which ordershouldthenurseperform
the following actions?
Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck by lifting the
newborn’s chin. Cleanse the skin around the newborn’s umbilical cord stump. Wash the newborn’s legs
andfeet. Cleanthenewborn’s diaper area.
- Usea headto toe,cleantodirtyapproach when washing [Show Less]
