ATI MATERNAL NEWBORN PROCTORED EXAM 2022/2023 LATEST UPDATE
A nurse provided discharge teaching to new parents on how to care for their newborn following
... [Show More] circumcision. Which of the following statements by the parents indicates the need for further clarification?
Select one:
a. "I should not remove the yellow exudate on the end of the penis."
b. "I will clean his penis with each diaper change."
c. "The circumcision will heal completely within a couple of weeks."
d. "I can give him a tub bath in two days."
d. "I can give him a tub bath in two days."
The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
Select one:
a. "My partner will put the condom on while his penis is erect."
b. "I will remove the condom 30 minutes after intercourse."
c. "My partner should leave an empty space at the tip."
d. "I can use spermicidal gels or creams to increase effectiveness."
b. "I will remove the condom 30 minutes after intercourse."
To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
Select one:
a. "When did your contractions begin?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
c. "What happens to your contractions when you move about?"
d. "Have you felt fetal movement over the last 24 hours?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1−3, to lochia serosa (pinkish brown) on days 4−9, to lochia alba (creamy white) days 10−21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1−3, to lochia serosa (pinkish brown) on days 4−9, to lochia alba (creamy white) days 10−21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a bright red, topinkish brown, to creamy white.
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?
Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
Correct: Late decelerations are associated with uteroplacental insufficiency and are a signof fetal hypoxia. Repeated late decelerations indicate fetal distress.
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?
Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of theclient and the family will be high. Inserting an indwelling catheter helps to keep thebladder empty and free from injury when the incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.
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.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
Select one:
a. "I should not remove the yellow exudate on the end of the penis."
b. "I will clean his penis with each diaper change."
c. "The circumcision will heal completely within a couple of weeks."
d. "I can give him a tub bath in two days."
d. "I can give him a tub bath in two days."
The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks.
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?
Select one:
a. "My partner will put the condom on while his penis is erect."
b. "I will remove the condom 30 minutes after intercourse."
c. "My partner should leave an empty space at the tip."
d. "I can use spermicidal gels or creams to increase effectiveness."
b. "I will remove the condom 30 minutes after intercourse."
To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?
Select one:
a. "When did your contractions begin?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
c. "What happens to your contractions when you move about?"
d. "Have you felt fetal movement over the last 24 hours?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.
False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes.
Telling the client to walk is not a correct response because it is an intervention rather than an assessment question.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response?
Select one:
a. The purpose of the NST is to assess the fetal CNS.
b. The purpose of the NST helps to determine gestational age.
c. The purpose of the NST is to determine fetal lie.
d. The purpose of the NST is to determine fetal breathing.
a. The purpose of the NST is to assess the fetal CNS.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
A) Acrocyanosis
B) Transient strabismus
C) Jaundice
D) Caput succedaneum - c) jaundice
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor ( SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
A) Large for gestational age
B) Hyperglycemia
C) Bradypnea
D) Vomiting - D) Vomiting
A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain ?
A) Decreased heart rate
B) Chin quivering
C) Pinpoint pupils
D) Slowed respirations - B) Chin quivering
A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? ( Use all the steps and list them in order)
A) Clean the newborn's diaper area
B) Wash the newborn's neck by lifting the newborn's chin.
C) Wipe the newborn's eyes from the inner canthus outward.
D) Cleanse the skin around the newborn's umbilical cord stump.
E) Wash the newborn's legs and feet. - C,B,D,E,A
A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following 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 - A) swelling of the face
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
A) Let me help you into a comfortable pushing position so you can begin bearing down.
B) I am going to call the doctor to get a prescription for medication to ripen your cervix.
C) I will give you some IV pain medicine to strengthen your contractions.
D) Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions. - D) Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.
A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
A) You can miss your period for several other reasons, describe your typical menstrual cycle.
B) If you have been sexually active and havent used protection, it is likely that you are pregnant.
C) Lets check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet?
D) Because you have missed your period, you should try taking a home pregnancy test before you start worrying. - A) You can miss your period for several other reasons, describe your typical menstrual cycle.
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?
A) Place warm, moist packs on the breast.
B) Apply cabbage leaves to the breast.
C) Wear a loose- fitting bra.
D) Put green tea bags on the breasts. - B) Apply cabbage leaves to the breasts.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? ( Select all that apply).
Heart Rate 154/min Axillary temperature 96.8 F Respiratory rate 58/min Length 43 cm (16.9in)
Weight 5lb 12 oz - Heart rate Respiratory
Weight
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take?
A) Take photos of the newborn to give to the parents.
B) Tell the parents that they can consider organ donations.
C) Encourage the parents to avoid allowing older children to visit them in the hospital.
D) Explain to the parents the need to name the newborn. - Take photos of the newborn to give to the parents.
A nurse is caring for a client who is 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
A) to estimate fetal weight
B) to locate a pocket of fluid
C) to determine multiparity
D) to pre-screen for fetal anomalies - B) to locate a pocket of fluid
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
A) Emotional lability
B) Focusing phase
C) Cognitive restructuring
D) Couvade syndrome - A) Emotional lability
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
A) Obtain an informed consent prior to obtaining the specimen
B) Collect at least milliliter of the urine for the test
C) Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen.
D) Premature newborns may have false negative tests due to immature development of liver enzymes. - C) Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen.
1. A nurse is assessing a client who has gestational diabetes and is experiencinghyperglycemia. Which of the following findings should the nurse expect?
a. Reports increased urinary output
b. Diaphoresis
c. Reports blurred vision
d. Shallow respirations
2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
a. Administer penicillin G 2.4 million units IM to the client
b. Instruct the client to schedule an annual pelvic examination
c. Tell the client she will start medication for HIV immediately after delivery
d. Report the client’s condition to the local health department
3. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverseeffect of this medication?
a. Depression [Show Less]