ATI Maternal Newborn Proctored Exam (20 Versions, 1500QA)/Maternal Newborn Proctored Exam
1. Two days after delivery, a postpartum client prepares for
... [Show More] discharge.
What should the nurse teach her about lochia flow?
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up
from the bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At
the peak of the contractions, the fetal heart rate has repeatedly dropped
30 beats/min below the baseline. Late decelerations are suspected and
the nurse notifies the physician. Which is the rationale for this action? .
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head
Maternal contractions are not adequate enough to deliver the fetus
The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a
client who is scheduled to have an emergency cesarean birth?
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about
postoperative care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother
regarding care of the breasts after discharge?
The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which
classification of drugs should the nurse anticipate administering?
Tocolytics
Anticonvulsants
Glucocorticoids
Anti-infective
6. Which of the following are probable signs, strongly indicating
pregnancy?
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
7. Two hours after delivery the nurse assesses the client and documents
that the fundus is soft, boggy, above the level of the umbilicus, and
displaced to the right side. The nurse encourages the client to void.
Which is the rationale for this nursing action?
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing
dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Ventrogluteal
Vastus lateralis
Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the
client voids 2,000 mL of urine. How should the nurse interpret this
finding?
High output renal failure
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot
maintain control of her blood sugar by diet alone, which medication will
she receive?
Metformin (Glucophage)
Glucagon
Insulin
11. Which assessment finding indicates that placental separation has
occurred during the third stage of labor?
Decreased vaginal bleeding
Contractions stop
Maternal shaking and chills
Lengthening of the umbilical cord
12. The nurse midwife is concerned about a pregnant client who is
suspected of having a TORCH infection. Which is the main reason
TORCH infections are grouped together? They are:
benign to the woman but cause death to the fetus.
sexually transmitted.
capable of infecting the fetus.
transmitted to the pregnant woman by a vector.
13. During the postpartum period, a hospitalized client complains of
discomfort related to her episiotomy. The nurse assigns the diagnosis of
“pain related to perineal sutures.” Which nursing intervention is most
appropriate during the first 24 hours following an episiotomy?
Instruct the client to use petroleum jelly on the episiotomy after voiding.
Encourage the client to practice Kegel exercises.
Advise the client to take a warm sitz bath every four hours.
Apply ice packs to the perineum.
14. A client asks the nurse about the benefits of breastfeeding. Which
response by the nurse provides the most accurate information?
Breastfeeding helps women lose weight faster.
Breast milk is easier to digest than formula.
Breastfeeding is a good method of contraception.
15. Which physiological change takes place during the puerperium?
The endometrium begins to undergo alterations necessary for
menstruation.
The placenta begins to separate from the uterine wall.
The uterus returns to a pre-pregnant size and location.
16. A client delivered two days ago and is suspected of having
postpartum "blues." Which symptoms confirm the diagnosis?
Uncontrollable crying and insecurity
Depression and suicidal thoughts
Sense of the inability to care for the family and extreme anxiety
Nausea and vomiting
17. Shortly after delivery, the nursery nurse gives the newborn an
injection of phytonadione (Vitamin K). The infant's grandmother wants
to know why the baby got “a shot in his leg.” Which response by the
nurse is most appropriate?
"Vitamin K promotes bone and muscle growth."
"Vitamin K helps the baby digest milk."
"Vitamin K helps stabilize the baby's blood sugar."
"Vitamin K is used to prevent bleeding."
18. At 10 weeks gestation, a primigravida asks the nurse what is
occurring developmentally with her baby. Which response by the nurse
is correct?
"The skin is wrinkled and fat is being formed."
"The eyelids are open and he can see."
"The kidneys are making urine."
19. A nurse in the clinic instructs a primigravida about the danger signs
of pregnancy. The client demonstrates understanding of the instructions,
stating she will notify the physician if which sign occurs?
Abdominal pain
20. An hour after delivery, the nurse instills erythromycin (Ilotycin)
ointment into the eyes of a newborn. The main objective of the treatment
is to prevent infection caused by which organism?
Gonorrhea
21. A woman in active labor receives a narcotic analgesic for pain
control. If the narcotic is given a half an hour before delivery, which
effect will the medication have on the infant? It will cause the infant's:
blood sugar to fall.
respiratory rate to decrease.
heart rate to increase.
movements to be hyperactive.
22. For a client in the second trimester of pregnancy, which assessment
data support a diagnosis of pregnancy-induced hypertension (PIH)?
Hemoglobin 10.2 mg/dL and uterine tenderness
Polyuria and weight loss of 3 pounds in the last month
Blood pressure 168/110 and 3+ proteinuria
Hematuria and blood glucose of 160 mg/dL
23. A 35-week gestation infant was delivered by forceps. Which
assessment findings should alert the nurse to a possible complication of
the forceps delivery?
Weak, ineffective suck, and scalp edema
Molding of the head and jitteriness
Shrill, high pitched cry, and tachypnea
Hypothermia and hemoglobin of 12.5 g/dL
24. In which position should the nurse place the laboring client in order
to increase the intensity of the contractions and improve oxygenation to
the fetus?
Left side-lying
High Fowler's
25. A woman enters the birthing center in active labor. She tells the
nurse that her membranes ruptured 26 hours ago. The nurse immediately
takes the client's vital signs. Which is the rationale for the nurse's
actions?
Pulse rates rise the longer the membranes are ruptured
Respiratory rates decrease due to lack of fluid in the uterus
Prolonged rupture of membranes can lead to transient hypertension
Infection is a complication of prolonged rupture of membranes
26. A new client's pregnancy is confirmed at 10 weeks gestation. Her
history reveals that her first two pregnancies ended in spontaneous
abortion at 12 and 20 weeks. She has a4-year-old and a set of 1-year-old
twins. How should the nurse record the client's current gravida and para
status?
Gravida 2, para 3
Gravida 4, para 2
Gravida 5, para 2
Gravida 5, para 4
27. A 16-year-old client reports to the school nurse because of nausea
and vomiting. After exploring the signs and symptoms with the client,
the nurse asks the girl whether she could be pregnant. The girl confirms
that she is pregnant, but states that she does not know how it happened.
Which nursing diagnosis is most important?
Knowledge deficit related to the client's developmental stage and age
28. A client is admitted to the hospital for induction of labor. Which are
the main indications for labor induction?
Placenta previa and twins
Pregnancy-induced hypertension and postterm fetus
Breech position and prematurity
Cephalopelvic disproportion and fetal distress
29. A client in active labor receives a regional anesthetic. Which is the
main purpose of regional anesthetics?
To relieve pain by decreasing [Show Less]