ATI Maternal Newborn & Peds
Maternal Newborn
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement.
... [Show More] Which of the following findings should the nurse report to the provider?
a. BUN 25 mg/dL b. serum creatinine 0.8 mg/dL c. urine output of 280 mL w/ 8 hr d. urine negative for ketones
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which statement should the nurse include in the teaching?
a. replace the diaphragm every 5 years b. leave the diaphragm in place for at least 6 hours after intercourse
c. use an oil-based product as a lubricant when inserting the diaphragm d.insert the diaphragm when bladder is full
A nurse is reviewing the med record of a client who is postpartum and has preeclampsia. Which lab results should the nurse report to the provider?
a. Hct 39% b. serum albumin 4.5g/dL c. WBC 9000/mm3 d. platelets 50,000/mm3
A nurse is teaching a client about Rho(D) immune globulin. Which statement by the client indicates an understanding of the teaching?
a. I will receive this med if my baby is Rh- b. I will receive this med when I'm in labor
c. I will need a 2nd dose of this med when my baby is 6wks old d.I will need this med if I have an amniocentesis
A nurse is assessing a client who is 30 weeks gestation during a routine prenatal visit. Which findings should the nurse report to the provider? a.swelling of the face b.varicose veins in the calves c.nonpitting 1+ ankle edema d.hyperpigmentation of the cheeks
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which actions should the nurse include in the plan?
a. feed the newborn 1oz of water q4hrs b. apply lotion to newborns skin 3x/day
c. remove all clothing from newborn except diaper d. discontinue therapy if the newborn develops a rash
A nurse is caring for a client who is 35 weeks gestation and is undergoing nonstress test that reveals a variable deceleration in the FHR. What action should the nurse take?
a. give the client oj b. elevate the client's legs c. have the client change positions d. establish IV access
A nurse is assessing a client who gave birth vaginally 12hrs ago and palpates her uterus to the right above the umbilicus. What interventions should the nurse perform?
a. reassess the client in 2 hrs b. administer simethicone
c. assist the client to empty her bladder d. instruct the client to lie on her right side
A nurse is performing a routine assessment on a client who is 18 weeks gestation. What findings should the nurse expect? a. deep tendon reflexes 4+ b. fundal height 14cm c. urine protein 2+ d. FHR 152/min
A nurse is teaching a new mother about steps the nurses will take to promote security and safety of the newborn. What statement should the nurse make?
a. we will prevent unidentified visitors from entering the unit
b. we will document the relationship of visitors in your medical record
c. your baby will stay in the nursery while you are asleep
d. staff members who take care of your baby will be wearing photo identification
A nurse is assessing the newborn of a client who took a SSRI during pregnancy. What manifestations should the nurse identify as an indication of withdrawal from and SSRI?
a. large for gestational age b. Hyperglycemia c. bradypnea d. vomiting
A nurse in an antepartum clinic is providing care for a client who is 26 weeks gestation. Upon reviewing her medical record, what findings should the nurse report to the provider?
a. 1-hr glucose tolerance test b. Hematocrit c. fundal height measurement d .FHR
A nurse is caring for a client following an amniocentesis at 18 wks gestation. What finding should the nurse report to the provider as a potential complication?
a. increased fetal movement b. leakage of fluid from the vag c. upper abd discomfort d. urinary frequency
A nurse is caring for a client who is in active labor and has no cervical change in the last 4 hrs. Which statement should the nurse make?
a. let me help you into a comfortable pushing position so you can begin bearing down
b. going to call the doc to get a script for meds to ripen your cervix
c. i will give you some IV pain med to strengthen your contractions
d. your provider will insert an intrauterine pressure cath to monitor the strength of your contractions
A nurse is caring for a client who is anemic at 32 wks gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. What outcomes should the nurse expect?
a. decrease uterine contractions b. increase in client's Hgb levels
c. reduction in resp distress in NB d. increase production of antibodies in NB
A nurse is teaching a client who is 10 wks gestation about nutrition during pregnancy. What statement by the client indicates an understanding of the teaching?
a. increase my protein to 60 g/day b. i should drink 2 L of water/day
c. increase my overall caloric intake by 300 calories d. take 600 mcg of folic acid each day
A nurse is teaching a client who is in preterm labor about terbutaline. What statement by the client indicates an understanding of the teaching?
a.i will get injections of the med once daily until my labor stops b.my blood sugar may be low while I am on this med
c. i will have blood tests because my K+ might decrease d. My BP may increase while I'm on this med
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. What cultural practices should the nurse include?
a. protect the client's head and feet from cold air b. bathe the client within 12 hr following delivery
c. ambulate the client within 24 hr of delivery d. offer the client a glass of milk with her first meal
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, what action should the nurse take next?
a. massage the client's fundus b. insert an indwelling urinary catheter
c. administer O2 at 10L/mind d. elevate the clients right hip
A nurse is caring for a client who is at 36 wks gestation and has a prescription for amniocentesis. For which reason should the nurse prepare the client for an ultrasound?
a. estimate fetal weight b. locate pocket of fluid c. determine multiparity d. prescreen for fetal anomalies
A nurse is demonstrating to a client how to bathe her newborn. What order should the nurse perform the following actions? a.clean the NB diaper area b.wash the newborn's neck by lifting the NB chin
c.wipe the NB eyes from the inner canthus outward d.cleanse the skin around the newborn's umbilical cord stump
e.wash the NB legs and feet
A nurse is assessing a newborn 12hrs after birth. What manifestation should the nurse report to the provider? a. Acrocyanosis b. transient strabismus c. jaundice d. caput succedaneum
a nurse is calculating a client's expected DOB using Naegele's rule. The client says her last menstrual cycle started Nov 27th. What date is the client's expected DOB? a. sept 3rd b. sept 20th c. aug 3rd d. aug 20th
A nurse is assessing a newborn following circumcision. What finding should the nurse identify as an indication that the newborn is experiencing pain?
a. decreased HR b. chin quivering c. pinpoint pupils d. slowed respirations
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. What response should the nurse make?
a. you can miss your period for several other reason. Describe your typical menstrual cycle.
A nurse is preparing to administer oxytocin to a client who is postpartum. What findings indicate the admin of the med SATA a. flaccid uterus c. excess vaginal bleeding
A nurse on the postpartum unit is caring for a client following a c-section. Priority? b. amount of lochia
A nurse is observing a new mother caring for her crying newborn who is bottle feeding/ What action by the mother should the nurse recognize as positive parenting behavior?
a. lays the newborn across her lap and gently sways b. places the newborn in the crib in a prone position
c offers the newborn a pacifier dipped in formula d. prepares a bottle of formula mixed with rice cereal
A nurse in a prenatal clinic is assessing a group of clients/ What client should the nurse request the provider to see first?
a. 11 wks gestation and reports and cramping
b. 15 wks gestation and reports tingling and numbness in her right hand
c. 20 wks gestation and reports constipation for past 4 days
d. 8 wks gestation and reports having 3 bloody noses in past week
A nurse is preparing to administer hep b immune globulin to the newborn. Prescription states, "administer 5mcg Im once today." available is a 5mL vial with 10mcg/mL. How many mL? 0.5
A nurse is assessing a newborn who was born at 26 wks gestation using the New Ballard Score. Which findings should the nurse expect? a. minimal arm recoil b. popliteal angle of 90 degrees
c. creases over the entire foot d. raised areolas with 3-4 mm buds
A nurse is caring for a client who is 38 wks gestation. What action should the nurse take prior to applying an external transducer for fetal monitoring?
a. determine progression of dilatation and effacement b. perform leopold maneuvers
c. complete a sterile speculum exam d. prepare a nitrazine paper test
A nurse is performing a physical assessment of a newborn. What clinical findings should the nurse expect? SATA a. HR 154/mon b. axillary temp 36 C (96.8F) c. resp rate 58/min
d. length 43 cm (16.9 in) e. weight 2.6 kg (5lb 12 oz)
A nurse is teaching a client at 35 wks gestation about clinical manifestations of potential preg complications to report to the provider. What manifestations should the nurse include?
a. SOB when climbing stairs b. swelling of feet and ankles at the end of the day
c. headache that is unrelieved by analgesia d. braxton hicks contractions
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states she is, "happy one minute and crying the next." the nurse should interpret the client's statement as an indication of which? a. emotional lability b. focusing phase c. cognitive restructuring d. couvade syndrome
A nurse is caring for a client who is in labor and whose fetus is in the right occiput post position. The client is dilated to 8cm and reports back pain. What action should the nurse take?
a. apply sacral counter pressure b. perform transcutaneous electrical nerve stimulation
c. initiate slow-paced breathing d. assist with biofeedback
A nurse is planning care for a client who is in labor and is to have amniotomy. What assessment should the nurse identify as the priority a. O2 saturation b. Temp c. BP d. urinary output
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. What action should the nurse take first? a. determine resp function b. increase the IV fluid rate
c. access emergency meds from cart d. collect maternal blood sample for coagulopathy studies
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 what location to begin assessing for fetal heart tones?
a. just above the umbilicus b. just above the symphysis pubis c. the RLQ d. The LLQ
A charge nurse on a labor delivery unit is teaching a newly licensed nurse how to perform leopold maneuvers. What indicates the first step of leopold maneuvers?
a hands on either side of baby's head b. one hand on baby's head
c. hands on either side of baby's bottom d. one hand on baby's back and one on baby's front
A nurse is planning discharge for a client who is 3 days postpartum. What nonpharmacological intervention should the nurse include in the plan of care for lactation suppression?
a. place warm, moist packs on the breast b. apply cabbage leaves to the breasts
c. wear a loose-fitting bra d. put green tea bags on the breasts
A nurse is planning care for a client who is to undergo a nonstress test. What action should the nurse include in the plan of care?
a. maintain the client NPO throughout the procedure b. place the client in a supine position
c. instruct the client to massage the abd to stimulate fetal movement
d. instruct the client to press the provided button each time fetal movement is detected
A nurse is caring for a client who is 36 wks gestation and has a positive contraction stress test. The nurse should plan to prepare the client for what diagnostic test?
a. biophysical profile b. Amniocentesis c. cordocentesis d. kleihauer-betke test
A nurse is caring for a prenatal client who has parvovirus b19 (fifth disease). What action should the nurse take? a. administer antiviral meds b. schedule an ultrasound exam
c. administer haemophilus influenzae type b vaccine d. schedule an indirect coombs test
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. What statement should the nurse include in the teaching?
a. obtain an informed consent prior to obtaining the specimen b. collect at least 1mL of urine for the test
c. ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen
d. premature newborns may have a false negative test due to immature development of liver enzymes.
A nurse on an antepartum unit is caring for 4 clients. What client should the nurse identify as priority?
a. gestational diabetes and a fasting glucose level of 120 b. 34 wks gestation and reports epigastric pain
c. 28 wks gestation and has a Hgb of 10.4 g/dL
d. a client who is at 39 wks gestation and reports urinary frequency and dysuria
A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching? a. you can share your room with your baby for the next few weeks
b. cover your baby with a light blanket while sleeping c. check the temp of the baby's bath water with your hand d. your baby can nap in her car seat during the day
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. What action should the nurse take? b. maintain the client on bedrest
A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report
which? A.reduced menstrual flow B.Breast tenderness C. SOB D. Headaches.
2. A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? B. 3.6 kg (8 lb) weight gain and is in her first trimester
A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th week of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? D. Orange Juice.
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity?
A. Alpha-fetoprotein (AFP) B. lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. indirect Coombs' test.
A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? C."You should empty your bladder prior to the procedure."
A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? A. Betamethasone
A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? SATA
A. Respirations less than 12/min B. Urinary output less than 30 ml/hr. C. Hyperreflexic deep-tendon reflexes D. decreased level of consciousness E. Flushing and sweating
A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? D. calcium gluconate
A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching?
C. "I plan to drink more orange juice while taking this pill." [Show Less]