ATI PROCTORED EXAM - MATERNAL NEWBORN
ATI PROCTORED EXAM - MATERNAL NEWBORN
A nurse is planning care for a newborn who is receiving phototherapy
... [Show More] for an elevated bilirubin level. Which of the following actions should the nurse take? -๐ D. Use a photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? -๐ Dark red vaginal bleeding
The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal bleeding.
A nurse is assessing a newborn and notes an axillary temperature of 96.9ยฐF (36ยฐC). Which of the following actions should the nurse perform? -๐ Correct Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia.
Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent.
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? -๐ Correct Answer:
C. Calcium gluconate
The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate.
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not magnesium sulfate.
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? -๐ Correct Answer:
"Place fresh cabbage leaves on your breasts."
After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts.
Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort.
The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts.
Leaves should be replaced when they become wilted.
Incorrect Answers:
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement and swelling.
C. Application of warmth to the breasts should be avoided because heat can stimulate milk production. An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk production rather than decrease it.
A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? -๐ Correct Answer:
D.
"You should eat dry foods that are high in carbohydrates when you wake up."
The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or crackers upon waking or when nausea occurs.
Incorrect Answers:
A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and vomiting.
B. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of nausea.
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? -๐ Correct Answer:
D.
"A progestin-only pill or injection is available for use while you are breastfeeding."
Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication.
Incorrect Answers:
A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and effective means of birth control. The client may experience an unplanned pregnancy if she waits until her periods resume before considering birth control options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not recommended for clients who are breastfeeding due to the risk of inhibiting breast milk production and supply.
C. Condoms and other non-hormonal birth control methods are appropriate for clients who are breastfeeding; however, there are other methods that are also appropriate.
A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? -๐ Correct Answer:
D.
Urine output 20 mL/hr
Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 mL/hr. The nurse should report this finding to the provider.
Incorrect Answers:
A. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within the expected reference range.
B. This temperature is within the expected reference range.
C. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should instruct the client to sit on the side of the bed before getting up, assist the client with ambulation, and implement general safety measures. However, it is not necessary to report this finding to the provider.
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? -๐ Correct Answer:
B."You will receive a medication to relax your uterus prior to the procedure."
A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider.
Incorrect Answers:
A. This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally and not internally.
C. External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency.
D. During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure.
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? -๐ Correct Answer:
D.
"This is a source of your fluid loss after delivery."
Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period.
Incorrect Answers:
A. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in blood volume.
B. Postpartum diuresis is caused by decreased estrogen levels. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period.
C. Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the lower extremities. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.
The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? -๐ Correct Answer:
C.
Autosomal recessive
PKU is inherited by autosomal-recessive gene patterns. In these types of disorders, neither parent may actually have the disorder, but both mother and father must carry and contribute a variant gene for it to occur. Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia.
Incorrect Answers:
A. PKU does not have an X-linked recessive pattern of inheritance. In X-linked recessive disorders, the abnormal gene is carried on the X chromosome. In males, only 1 copy of the abnormal gene is required for the disorder to be expressed in males since the Y chromosome does not carry the disorder. Females must have 2 copies of the gene. Examples of this type of disorder are hemophilia and color blindness.
B. PKU does not have an X-linked dominant pattern of inheritance. In X-linked dominant disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene is necessary for the disorder to occur. However, males are more likely to be severely affected due to the homozygous expression. There are only a few disorders that follow this pattern of inheritance. Examples include vitamin D-resistant rickets and Rett syndrome.
D. PKU does not have an autosomal-dominant pattern of inheritance. In these disorders, only 1 copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder are neurofibromatosis and Treacher Collins syndrome.
A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? -๐ Correct Answer:
C. Stress incontinence
The nurse should teach the client that stress incontinence can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra.
Urinary incontinence and uterine displacement can occur because of common age-related changes but are not necessarily a result of menopause-related changes.
Incorrect Answers:
A. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra.
B. The nurse should teach the client that hematuria is a manifestation of irritation to the bladder mucosa and might indicate a urinary tract infection. It is not an expected change associated with menopause.
D. The nurse should teach the client that vaginal dryness can occur with menopause due to the vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful intercourse.
A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? -๐ Correct Answer:
B.Sponge bathe the newborn every other day
Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed.
Incorrect Answers:
A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water.
C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin.
D. The parents should maintain the bath water temperature between 38ยฐ and 40ยฐC (100ยฐ and 104ยฐF).
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? -๐ Correct Answer:
Apply cold ice packs to the client's perineum
A third-degree laceration extends from the perineum to the external sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort.
Incorrect Answers:
A. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is recommended within the first 24 hours to reduce edema and promote comfort.
B. The nurse should encourage the client to sit on firm surfaces. The client should avoid soft pillows and donut pillows because they separate the buttocks and decrease venous blood flow, resulting in more pain and discomfort to the perineal area.
D. The use of suppositories or enemas is contraindicated for a client who has a third-degree perineal laceration due to the severity of the laceration.
A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? -๐ Correct Answer:
"I will place my baby on his back when putting him to sleep."
Newborns should always sleep on the back to prevent sudden infant death syndrome.
Incorrect Answers:
B. The parents should not place the newborn's crib close to a heat source due to the risk of the crib linen catching on fire.
C. The parents should always place the newborn in an approved car seat while driving with the newborn. Infant carriers are not approved safety seats for motor vehicles.
D. The parents should never tie any type of string or cord around the newborn's neck due to the risk of strangulation.
A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? -๐ Correct Answer:
Abundant lanugo
Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead.
Incorrect Answers:
B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term newborns demonstrate moderate flexion of the arms and legs.
C. Newborns who are premature have few heel creases. Full-term newborns have heel creases that cover most of the bottom of the feet.
D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero. Post-mature newborns are likely to have dry, parchment-like skin.
A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? -๐ Correct Answer:
Assess the newborn for respiratory depression
Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration.
This medication crosses the placenta and causes respiratory depression in the newborn, which peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication.
Incorrect Answers:
A. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses through stimulation of the mu and kappa opioid receptors.
C. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status.
D. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long period of time during pregnancy. A client receiving an opiate during labor would not lead to opiate dependence in the newborn.
A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? -๐ Correct Answer:
Urinary retention
After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors.
Incorrect Answers:
A. Breast engorgement does not generally become problematic until 3 to 5 days after birth.
B. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8 hours after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed blanket.
D. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of labor.
A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? -๐ Correct Answer:
Fetal gastrointestinal anomaly
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios.
Incorrect Answers:
A. Polyhydramnios will result in a fundal height greater than expected for gestational age.
B. Polyhydramnios will result in an increase in weight gain, not a decrease.
C. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of amniotic fluid surrounding the fetus.
A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? -๐ Correct Answer:
"You should slightly increase your exposure to sunlight."
Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching.
Incorrect Answers:
B. Pruritus gravidarum is a condition of pregnancy that causes generalized itching that occurs due to the stretching of the skin. It will resolve without extensive treatment after delivery.
C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no effect on the liver. Therefore, the client will not require weekly liver function studies.
D. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant due to its teratogenic effects on the fetus.
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? -๐ Correct Answer:
Pelvic inflammatory disease (PID)
An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta, and the fetus begin to develop in this area.
The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy.
Incorrect Answers:
A. Anemia does not place the client at increased risk of an ectopic pregnancy.
B. Frequent urinary tract infections do not increase the risk of ectopic pregnancy.
C. A previous cesarean birth does not place the client at increased risk of an ectopic pregnancy.
A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect?
Show Explanation -๐ Correct Answer:
Dark brown vaginal discharge
A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi that gives rise to multiple cysts.
The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape-like clusters.
Incorrect Answers:
A. The nurse should expect the client's temperature to be within the expected reference range because a hydatidiform mole does not lead to hypothermia.
C. The nurse should expect the client to have increased urinary output due to the elevated maternal blood volume and pressure of the uterus on the maternal bladder.
D. The nurse should not expect to hear fetal heart tones because a viable embryo or fetus is not present.
A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider?
Show Explanation -๐ Correct Answer:
Frequent headaches
The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the face and fingers, visual disturbances, and epigastric pain are associated with preeclampsia.
Incorrect Answers:
B. Leukorrhea is a common discomfort of pregnancy and is an abundant amount of vaginal mucus that may occur throughout pregnancy.
C. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen.
D. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of the nerves and does not need to be reported to the provider.
A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? -๐ Correct Answer:
Renal agenesis
Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios.
Incorrect Answers:
A. Fetal cardiac anomalies do not affect the volume of amniotic fluid.
C. Fetal neural tube defects do not affect the volume of amniotic fluid.
D. Fetal hydrocephalus does not affect the volume of amniotic fluid.
A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3ยฐC (99.2ยฐF), and pulse rate 52/min. Which of the following actions should the nurse take?
Show Explanation -๐ Correct Answer:
Ask the client when she last voided
Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.
Incorrect Answers:
A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum. A pulse of 52/minute is within the expected reference range.
B. The nurse should massage the fundus when it is boggy.
D. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.
A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion?
Show Explanation -๐ Correct Answer:
Maternal hypotension
Maternal hypotension is a common adverse effect of a spinal block. To prevent supine hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the uterus.
Incorrect Answers:
B. Spinal anesthesia is more likely to cause fetal bradycardia than fetal tachycardia.
C. Spinal anesthesia is more likely to cause minimal or a lack of fetal heart rate variability than increased fetal heart rate variability.
D. Spinal anesthesia is more likely to cause a fever than hypothermia.
A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?
Show Explanation -๐ Correct Answer:
Daily weight
Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status.
Incorrect Answers:
A. The nurse should assess the client's blood pressure to evaluate circulatory status. However, evidence-based practice indicates that another assessment provides more accurate information.
B. The nurse should assess the client's intake and output to evaluate fluid status. However, evidence-based practice indicates that another assessment provides more accurate information.
D. The nurse should assess the severity of the client's edema to evaluate fluid status. However, evidence-based practice indicates that another assessment provides more accurate information.
A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first?
Show Explanation -๐ Correct Answer:
Massage the fundus
The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client.
When there are several risks to client safety, the one posing the greatest threat is the highest priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by a relaxed, boggy uterus.
Thus, the greatest risk for this client is hemorrhage. The nurse should massage the client's fundus first. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.
Incorrect Answers:
A. A full bladder can cause uterine atony. However, there is another action the nurse should take first.
C. Vital signs are important but will not help in identifying the reason for this client's bleeding. There is another action that the nurse should take first.
D. Administering carboprost is an appropriate action for managing postpartum hemorrhage. However, there is another action the nurse should take first.
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take?
Show Explanation -๐ Correct Answer:
Provide a sitz bath with warm water for the client
The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which helps relieve the pulling and stinging associated with the healing incision. The warm water increases blood flow to the area through vasodilatation, which also promotes healing and comfort.
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