2024 ATI MATERNAL NEWBORN ASSESSMENT A WITH CORRECT ANSWERS, Exams of Advanced Education

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2024 ATI MATERNAL NEWBORN

ASSESSMENT A WITH CORRECT

ANSWERS

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when using the ABCs approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. the greatest risk to the client is bleeding and postpartum hemorrhage. a nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. the client is dilated to 8cm and reports back pain. which of the following actions should the nurse take? a. apply sacral counter pressure b. perform trancutaneous electrical nerve stimulation (TENS) c. initiate slow-paced breathing d. assist with biofeedback - CORRECT ANSWERS- a. apply sacral counter pressure A nurse on the postpartum unit is caring for a pt. following a cesarean birth. Which of the following assessments is the nurse's priority? a. parent-child attachment

b. amount of lochia c. patency of the IV catheter d. quality and quantity of urine - CORRECT ANSWERS- b. amount of lochia when using the urgent vs nonurgent approach to care, the nurse should determine that the priority finding is a client who is 11 weeks gestation and reports abdominal cramping. abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. the nurse should request that the provider see this client first b. Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation.. c. Constipation is nonurgent because it is common discomfort related to pregnancy for a client who is at 20 weeks of gestation. d. Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. a nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her uterus to the right above the umbilicus. which of the following interventions should the nurse perform? a. reassess the client in 2 hours b. administer simethicone c. assist the client to empty her bladder

d. instruct the client to lie on her right side - CORRECT ANSWERS- c. assist the client to empty her bladder the nurse should apply sacral counter pressure to assist in relieving back labor pain related to fetal posterior position b. the nurse should perform TENS during the first stage of labor. c. the nurse should transition a client to pattern-paced breathing during this stage of labor. d. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor. a nurse is demonstrating to a client how to bathe her newborn. in which order should the nurse perform the following actions a. wipe the newborn's eyes from inner canthus outward b. wash the newborn's legs and feet c. wash the newborn's neck by lifting the newborn's chin d. cleanse the skin around the newborn's umbilical stump e. clean the newborn's diaper area - CORRECT ANSWERS- a. wipe the newborn's eyes from inner canthus outward

c. wash the newborn's neck by lifting the newborn's chin d. cleanse the skin around the newborn's umbilical stump b. wash the newborn's legs and feet e. clean the newborn's diaper area The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. 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 donation 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 - CORRECT ANSWERS- a. take photos of the newborn to give to the parents the nurse should create a memory box that includes mementos of the newborn (ex: photos, ID bands, newborn hat and blanket) b. Organ donation can be considered if a newborn is delivered alive.

c. The nurse should encourage the client to allow older children to come to the hospital as a beneficial part of the grieving process. d. The nurse should explain to the client that naming the baby can be helpful during the grieving process, but it is not a requirement. a nurse is caring for a client who is 36 weeks gestation and has a positive contraction stress test. the nurse should plan to prepare the clients for which of the following diagnostic tests? a. biophysical profile b. amniocentesis c. cordocentesis d. Kleihauer- Burke test - CORRECT ANSWERS- a. biophysical profile a positive contraction stress test indicate further evaluation of the fetus is necessary. a biophysical profile will provide further evaluation with real-time ultrasound b. An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. c. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia.

d. The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization. a nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. which of the following laboratory results should the nurse report to the provider? a. hct 39% b. serum albumin 4.5 g/dL c. WBC 9,000/mm d. platelets 50,000/mm3 - CORRECT ANSWERS- d. platelets 50,000/mm a platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. the nurse should report this result to the provider a. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. b. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. c. A WBC of 9,000/mm3 is within the expected reference range. a nurse is assessing a newborn who was born at 26 weeks gestation using the Ballard score. which of the following findings should the nurse expect?

a. minimal arm recoil b. popliteal angle of 90 c. creases over the entire foot sole d. raised areolas with 3-4mm buds - CORRECT ANSWERS- a. minimal arm recoil the nurse should expect a newborn that was born at 26 weeks to have decreased muscular tone or minimal arm recoil b. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. c. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. d. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks. a nurse is assessing a newborn following a circumcision. which of the following findings should the nurse identify as an early indication that the newborn is experiencing pain? a. decrease heart rate b. chin quivering

c. pinpoint pupils d. slowed respirations - CORRECT ANSWERS- b. chin quivering behavioral responses to a newborn's pain include facial expressions (ex: chin quivering, grimacing, furrowing of brow) a. The heart rate will increase when a newborn is experiencing pain. c. When experiencing pain, a newborn's pupils typically dilate. d. When experiencing pain, a newborn's respirations are typically rapid and shallow. a nurse is assessing the newborn of a client who took a 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 - CORRECT ANSWERS- d. vomiting expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. these manifestations typically last 2 days

a. Low birth weight is an expected clinical manifestation of fetal exposure to SSRIs. b. Hypoglycemia is an expected clinical manifestation of fetal exposure to SSRIs. c. Tachypnea is an expected clinical manifestation of fetal exposure to SSRIs. a nurse is developing a plan of care for a newborn who is to undergo photo-therapy for hyperbilirubinemia. which of the following actions should the nurse include in the plan? a. feed the newborn 1 oz of water every 4 hours b. apply lotion to the newborn's skin 3 times per day c. remove all clothing form the newborn except the diaper d. discontinue therapy if the newborn develops a rash - CORRECT ANSWERS- c. remove all clothing from the newborn except the diaper the nurse should remove all of the newborn's clothing except the diaper while under photo-therapy. maximum ski exposure to the ultraviolet light is needed to break down the excess bilirubin. a. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin or provide nutritional value.

b. The nurse should not apply lotion or creams to a newborn who is undergoing phototherapy. Lotions and creams can absorb heat and lead to burns. d. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment. a nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. which of the following cultural practices should the nurse include in plan of care? a. protect head and feet from cold air b. bathe the client within 12 hours following delivery c. ambulate the patient within 24 hr following delivery d. offer the patient a glass of cold milk with her first meal - CORRECT ANSWERS- a. protect head and feet from cold air protecting the client's head and feet from cold air should be included in the plan of care because it is traditional Hispanic practice during the postpartum period. b. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. c. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery.

d. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth. a nurse is caring for a client who is at 38 weeks gestation. which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. determine progression of dilation and effacement b. perform the Leopold maneuver c. complete a sterile speculum exam d. prepare a nitrazine paper test - CORRECT ANSWERS- b. perform the Leopold maneuver the nurse should perform Leopold maneuver to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer a. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. c. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. d. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

a nurse is caring for a client who is in active labor and has no cervical changes in the last 4 hours. 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 you a prescription for medication to ripen your cervix" c. " I will give you some IV pain medication to strengthen your contraction" d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions - CORRECT ANSWERS- d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor a. The nurse should not instruct the client to start bearing down until the second stage of labor. b. A cervical ripening agent is not used during the active stage of labor. c. Administering IV pain medication can decrease the intensity of uterine contractions. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

a. massage the client's fundus b. insert an indwelling urinary catheter c. administer oxygen at 10L/min d. elevate the client's right hip - CORRECT ANSWERS- a. massage the client's fundus the greatest risk to the client is hemorrhage. therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions b. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. c. The nurse should administer oxygen at 10 L/min to enhance perfusion. However, this is not the next action the nurse should take. d. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take. a nurse is reviewing the medical record of a client who is one day postpartum. the client had a vaginal birth with a 4th degree perineal laceration. the nurse should contact the provider regarding which of the following prescriptions? a. docusate sodium 100mg PO TID b. sitz bath 2-3 times per day PRN pain

c. bisacodyl rectal suppository daily PRN constipation d. ibuprofen 600mg PO Q 6hours PRN pain - CORRECT ANSWERS- c. bisacodyl rectal suppository daily PRN constipation the nurse should NOT administer a rectal suppository or enema to a client who has a 4th degree perineal laceration. these can cause separation of the suture line, bleeding, or infection a. Docusate sodium is a stool softener that is often prescribed following birth. The client should take a stool softener until the perineum is healed. Hard stool can separate the suture line between the vagina and rectum, leading to bleeding and infection. b. A sitz bath filled with warm water is soothing to the perineum. The warm water also increases blood flow to the tissues, promoting healing. The nurse should encourage the client to use a sitz bath two to three times per day, or as often as needed, to decrease perineal pain. d. Ibuprofen is a nonsteroidal, anti-inflammatory medication that is used to decrease pain and swelling. The client who has a fourth-degree perineal laceration will likely receive scheduled ibuprofen as well as an opioid analgesic as needed for breakthrough pain. a nurse is caring for a client who is at 26 weeks gestation and has epilepsy. the nurse enters the room and observes the client having a seizure. after turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? a. monitor the FHR

b. assess uterine activity c. administer oxygen via nonrebreather mask d. start a bolus of IV fluids - CORRECT ANSWERS- c. administer oxygen via nonrebreather mask when using the ABCs approach to the client care, the nurse should take priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus a. The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. b. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. d. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next. a nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks 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 you period for several other reasons. describe your typical menstrual cycle" b. "if you have been sexually active and haven't used protection, it is likely that you are pregnant"

c. "let's 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" - CORRECT ANSWERS- a. "you can miss you period for several other reasons. describe your typical menstrual cycle" amenorrhea is a presumptive sign of pregnancy, not a positive sign. therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. b. The nurse's response dismisses the client's concerns, which can cause the client to have increased anxiety. c. The nurse's response is making a false assumption that the client is pregnant based only on the client's statement. The nurse should gather more information from the client before making any false assumptions. d. The nurse's response dismisses the client's concerns and does not answer or address the client's question, which can increase the client's anxiety level. a nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes. which of the following instructions should the nurse include in the teaching? a. "you should get a 2 hour glucose test in 6-12 weeks" b. "you should avoid using low-dose oral contraceptives for birth control" c. "you will need to monitor you blood glucose levels daily at home for 2-3 weeks"

d. "you will need to take a lower dose of insulin than you took during you pregnancy" - CORRECT ANSWERS- a. "you should get a 2 hour glucose test in 6- weeks" the nurse should instruct the client to get a 2 hour oral glucose tolerance test 6- weeks postpartum and every 3 years to screen for type 2 diabetes b. The nurse should instruct the client that low-dose oral contraceptives are safe to use for clients who have a history of gestational diabetes mellitus. c. The nurse should instruct the client that blood glucose levels return to the expected reference range after childbirth. Therefore, the client does not need to monitor her blood glucose levels at home. d. The nurse should instruct the client that blood glucose levels return to the expected reference range after childbirth. Therefore, the client does not need to continue to take insulin. A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? a. a client who has gestational diabetes and a fasting blood glucose level of 120mg/dL b. a client who is at 34 weeks of gestation and reports epigastric pain c. a client who is at 28 weeks gestation and has an hgb of 10.4g/dL d. a client who is at 39 weeks of gestation and reports urinary frequency and dysuria - CORRECT ANSWERS- b. a client who is at 34 weeks of gestation and reports epigastric pain

epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. therefore, the nurse should identify this client as the priority. a. A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes. However, this is a non-urgent finding, which means that another client is the nurse's priority. c. This finding is a clinical manifestation of anemia in a client who is pregnant, which is a non-urgent condition. Therefore, another client is the nurse's priority. d. Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition. Therefore, another client is the nurse's priority. a nurse is preparing to administer oxytocin to a client who is postpartum. which of the following findings is an indication for the administration of the medication? select all that apply a. flaccid uterus b. cervical laceration c. excess vaginal bleeding d. increased afterbirth cramping e. increased maternal temp - CORRECT ANSWERS- a. flaccid uterus c. excess vaginal bleeding

oxytocin increases the contractibility of the uterus. oxytocin enhances uterine contractibility, decreasing vaginal bleeding. b. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. d. The use of oxytocin will increase, rather than decrease, afterbirth cramping. e. The use of oxytocin will have no effect on maternal temperature. a nurse is caring for a full-term newborn immediately following birth. which of the following actions should the nurse take first? a. assign apgar score to the newborn b. weigh the newborn c. place identification bracelets on the newborn d. dry the newborn - CORRECT ANSWERS- d. dry the newborn when using the urgent vs. non-urgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. therefore, the first action the nurse should take immediately after birth is to dry the newborn. a. The nurse should obtain Apgar scores at 1 and 5 min after birth. Therefore, this is not the first action the nurse should take.

b. The nurse should obtain the newborn's weight shortly after birth to obtain a baseline. However, this is not the first action the nurse should take. c. The nurse should place identification bracelets on the newborn shortly after birth. However, this is not the first action the nurse should take. A nurse is performing a physical assessment of a newborn. which of the following clinical findings should the nurse expect? (Select all that apply) a. Heart rate 154/min b. Axillary temperature 36 C (96.8 F) c. Respiratory rate 58/min d. Length 43 cm (16.9 in) e. Weight 2.6 kg (5 lb 12 oz) - CORRECT ANSWERS- a. Heart rate 154/min c. Respiratory rate 58/min e. Weight 2.6 kg (5 lb 12 oz) a. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. c. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. e. The expected reference range for a newborn's weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb).

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b. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5 F). d. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. there are three tabs that contain separate categories of data.) Vital Signs: BP 130/78 mmHg; ~RR 20/min;~ HR 90/min Lab Results: hemoglobin 12 g/dL;~hematocrit 34%; ~1-hr glucose tolerance test 120 mg/dL Progress Note: Fundal height 30 cm~ good fetal movement; not experiencing headache, dizziness, blurred vision, or vaginal bleeding; fetal heart rate 110/min. a. 1 hr glucose tolerance test b. hematocrit c. fundal height measurement d. fetal heart rate (FHR) - CORRECT ANSWERS- c. Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.

a. A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. b. A hematocrit of 34% is within the expected reference range for this client. The level should be greater than 33%. d. This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation. a nurse for a client who is anemic at 32 weeks gestation and is in preterm labor. the provider prescribed betamethasone 12mg IM. which of the following outcome should the nurse expect? a. decreased uterine contractions b. in increase in the client's hemoglobin levels c. a reduction in respiratory distress in the newborn d.increased production of antibodies in the newborn - CORRECT ANSWERS- c. a reduction in respiratory distress in the newborn betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. a. This is not an expected outcome of betamethasone. b. This is not an expected outcome of betamethasone.

d. This is not an expected outcome of betamethasone. a nurse is teaching a client who is at 8 weeks gestation about exercise. which of the following instructions should the nurse include in the teaching? a. "you should increase weight-bearing exercises as your pregnancy progresses" b. "you should lie on your back to rest for 5 minutes after exercising" c. "you should take your pulse every 20 minutes while your are exercising" d. "you should exercise for 30 minutes each day" - CORRECT ANSWERS- d. "you should exercise for 30 minutes each day" the nurse should instruct the client to engage in 30 minutes of moderate exercise every day to improve muscle tone throughout pregnancy a. The nurse should instruct to client to decrease, rather than increase, weight- bearing exercises as the pregnancy progresses. b. The nurse should instruct the client to rest in a lateral position for 10 min following exercise.. c. The nurse should instruct the client to take her pulse every 10 to 15 min during exercise, rather than every 20 min. a nurse is assessing a newborn 12 hours after birth. which of the following manifestations should the nurse report to the provider?

a. acrocyanosis b. transient strabismus c. jaudice d. caput succedaneum - CORRECT ANSWERS- c. jaundice jaundice occurring within the first 24 hours of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. the nurse should report this manifestation to the provider. a. Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 12 hr after birth. b. Transient strabismus is a normal variation in the newborn's eyes that can persist until 4 months of age. d. Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput. a nurse is planning care for a client who is to undergo a nonstress test. which of the following actions 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 abdomen to stimulate fetal movement d. instruct the client to press the provided button each time fetal movement is detected - CORRECT ANSWERS- d. instruct the client to press the provided button each time fetal movement is detected fetal movement may not be evident on the fetal monitor and tracing. instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. a. There is no indication for the client to be NPO. Sometimes, clients are encouraged to drink liquids to promote adequate hydration. b. The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to promote uterine perfusion and prevent supine hypotension. c. Massaging the abdomen does not stimulate fetal movement. a nurse is teaching a client who is 35 weeks gestation about clinical manifestations of potential pregnancy complications to report to the provider. which of the following manifestations should the nurse include? a. shortness of breath 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 - CORRECT ANSWERS- c. headache that is unrelieved by analgesia