ATI Maternal newborn 2019
1. A nurse is assessing a newborn following a forceps assisted birth. Which of the following clinical manifestations should
... [Show More] the nurse identify as a complication of the birth method?
A. Hypoglycemia
B. Polycythemia
C. Facial Palsy
D. Bronchopumonary dysplasia
2. A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching?
“The medication could cause me to experience heart paptation”
“This medication could cause me to experience blurred vision”
“This medication could cause me to experience ringing in my ears”
“This medication could cause me to experience frequent …”
4. A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
Urine Ketones
Rapid plasma regain
Prothrombin time
Urine culture
5. 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?
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
6. 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
7. 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
8. 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 concentration 200 mg/ 24 hr
B. Creatnine 0.8 mg/ dL
C. Hemoglobin 14.8 g/ dL
D. Platelet Count 60.000/ mm3
9. A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
A. Tinnitus
B. Urinary Frequency
C. Breast Tenderness
D. Chills
10. A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
A. Bulging Fontanels
B. Nasal Flaring
C. Length from head to heel of 40 cm (15.7 in)
D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
11. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care.
A. Increase the newborn’s visual stimulation
B. Weigh the newborn every other day
C. Discourage parental interaction until after a social evaluation
D. Swaddle the newborn in a flexed position
12. A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
A. Obtain a blood sample for a serum glucose level
B. Feed the newborn immediately
C. Administer 50 mL of dextrose solution IV
D. Reassess the blood glucose level prior to the next feeding
13. A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply).
A. “I will limit my time in the hot tub to 30 minutes 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 exercise sessions.”
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.”
14. 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. Contraction durations of 95 to 100 seconds
B. Contraction frequency of 2 to 3 min apart
C. Absent early deceleration of fetal heart rate
D. Fetal heart rate is 140/min
15. 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
16. 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
17. 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
18. 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. Use Nagele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
1. To compute the EDD using the naegele's rule, we add 7 days from the last day of LMP then subtract 3 months and add 1 year. Thus the EDD for this patient is December 13, 2021 (1213)
2. D. the client delivers the newborn
• The second stage of labor starts with full dilation of the cervix and it ends with expulsion of the fetus
19. 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
20. A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse?
A. “It burns when I urinate
B. “My feet are really swollen today”.
C. “I didn’t have lunch today, but I have breakfast this morning”.
21. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
A. “I should position my baby’s car seat at a 45 degree angle in the car.”
B. “I should place the car seat rear facing until my baby is 12 months old.”
C. “I should place the harness snugly in a slot above my baby’s sholders.” D. “I should position the retainer clip at the top of my baby’s abdomen.”
22. A nurse is developing an educational program about hermolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hermolytic disease?
A. The mother is Rh positive and the father is Rh negative
B. The mother is Rh negative and the father is Rh positive
C. The mother and the father are both Rh positive
D. The mother and the father are both Rh negative
23. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
A. A client who has diabetes mellitus and an HbA1c of 5.8%
B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL
C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36%
E. “I have been seeing spot this morning”
24. A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
a. Molding
b. Vernix Caseosa
c. Acrocyanosis
d.Sternal retractions
25. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
A client who has a urinary output of 300 ml in 8 hr
A client who reports abdominal cramping during breastfeeding
A client who is receiving magnesium sulfate and has absent deep tendon reflexes
A client who reports lochia rubra requiring changing perineal pads every 3 hr
26. A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer?
Metronidazole
Penicillin
Acyclovir
Gentamicin
27. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications?
Hyperemesis
Proteinuria
Hypoxia
Hemorrhage
28. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
Increase the infusion rate every 30 to 60 min.
Maintain the client in a supine position.
Titrate the infusion rate by 4 milliunits/min.
Limit IV intake to 4 L per 24 hr.
29. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the “Exhibit” Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
Administer nitric oxide inhalation therapy to the newborn
Insert an orogastric decompression tube with low wall suction.
Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
Measure the aadbominal circumference at the level of the newborn’s umbilicus every 2 hr.
30. A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take?
Decrease maintenance IV solution infusion rate.
Place the client in lateral position.
Administer misoprostol 25 mcg vaginally
Administer oxygen via face mask at 2 L/min
31. A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
Use a fetal scalp electrode during labor and delivery.
Administer a pneumococcal immunization to the newborn within 4 hr following birth. Bathe the newborn before initiating skin-to-skin contact
32. A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?
Blood pressure 142/92 mm Hg
Urine output 100 mL in hr
Pulse 58/min
Respiratory rate 14/min
33. A nurse is reviewing laboratory results for client who is pregnant. The Nurse should expect which of the following laboratory values to increase?
RBC count
Bilirubin
Fasting blood glucose
Bun
None of the above
34. A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of
dexamethasone 6 mg IM 12 hr. Available in dexamethasome 10 mg/mL. How mane mL of dexamethasome should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)
0.6 mL.
35. A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
A. A client who has an ultrasound that confirms a molar pregnancy
B. A client who has a crown-rump length of 7 weeks gestation
C. A client who has a positive urine pregnancy test 1 week after missed menses
D. A client who has felt quickening for the first time
36. A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Dress the newborn in lightweight clothing.
B. Avoid using lotion or ointment on the newborn skin.
C. Keep the newborn supine throughout treatment
D. Measure the newborn’s temperature every 8hr
37. A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which of the following results require intervention by the nurse?
A. WBC count 10,000/mm3
B. Platelets 180,000/mm3
C. Hemoglobin 20g/dL
D. Glucose 20 mg/dL
38. A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? ( select all that apply).
A. Amnionitis
B. Urinary tract infection
C. Polyhydramnios
D. Leakage of amniotic fluid
E. Preterm labor
39. A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
A. Assisting a mother with breastfeeding
B. Performing a newborn’s initial bath
C. Administering the measles, mumps, rubella vaccine
D. Performing umbilical cord care
40. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy . This of the following statements by the client indicates an understanding of the teaching.
A. “I will count baby’s lacks every other day.
B. “I will alternate the arm use to check my blood pressure.
D. I will consume 50 grams of protein daily
41. A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
A. newborn who has nasal flaring
B. newborn who has subconjunctival hemorrhage of the left ey
C. A newborn who has overlapping suture lines
D. A newborn who has not rust-stained urine
42. A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
A. Meconium – start fluid
B. placenta previa
C. Midline episiotomy
D. Gestational hypertension
43. A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
A. Administer indomethacin
B. Insert a second using a 22 gauge IV catheter,
C. Insert an indwelling urinary catheter.
D. Administer oxygen at 4L/min via nasal cannula.
44. A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth.
A. Pneumococcal
B. Hepatitis
C. Human papillomavirus
D. Rubella
45. caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider?
A. Hgb 20 g/dL
B. Bilirubin 2mg/dL
C. Platelets 200 .000/mm3
WBC count 32.000/mm3
46. A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
A. Give the newborn a warm bath.
B. Apply a cap to the newborn head.
C. Reposition the newborn.
D. Obtain an oxygen saturation level [Show Less]