ATI 2023 Maternal Newborn Test A and B questions with complete solutions rated, Exams of Nursing

Download ATI 2023 Maternal Newborn Test A and B questions with complete solutions rated and more Exams Nursing in PDF only on Docsity! ATI 2023 Maternal Newborn Test A and B questions with complete solutions rated ATI 2023 Maternal Newborn Test A and B ati pn maternal newborn 30TH JUNE bravel radon [Company address] Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min Maternal history of methadone use during pregnancy. Which should the Nurse report? Respiratory findings Temperature Oxygen saturation Central nervous system findings Gastrointestinal findings - correct answer ✔✔Gastrointestinal findings Central nervous system findings Client reports a small amount of bright red blood in their underwear upon awakening. Client denies contractions or abdominal pain. External fetal monitor applied. Potential Nursing Action Indicated or Contraindicated Assess cervical dilation Weigh perineal pads. Administer methotrexate. Insert a large bore intravenous catheter. - correct answer ✔✔Contraindicated Assess Cervical Dilation - She's currently bleeding and not in the middle of labor, unnecessary. Administer Methotrexate - She isn't having an ectopic pregnancy - this is used to resolve ectopic pregnancies in the first trimester. Day 2, 0900: Newborn awake, alert, and crying. Loosely<<<< wrapped in one blanket. Mild tremors noted. Yellow discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal flaring noted. Diaper changed for small amount of urine and transitional stool. Day 2, 0915:Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL Potential Condition? - It's NOT NAS since Mom wasn't on opiates. It's NOT Bilirubin issues so no phototherapy. None of the babies S/S point to Respiratory distress either. COLD STRESS Encourage parent to breastfeed Place newborn skin to skin on birthing parents chest. Temperature - correct answer ✔✔ 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? Administer Penicillin g2.4 million units - No, this should be done for syphilis. Instruct Client to schedule annual pelvic examination - NO - should be every 6 months. Tell the client they'll start medication for HIV immediately after delivery. NO - It will begin DURING the prenatal AND perinatal periods to decrease the risk of transmission to the newborn. Report the client's condition to the local health department. YES - HIV is one of the conditions that is REQUIRED to be reported. - correct answer ✔✔Report the client's condition to the local health department. A nurse is reviewing the laboratory results for a client who is at 10 weeks gestation which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10g/dL YES - this is below the 11 g/dL minimum for pregnant women. WBC Count - 15,000 - NO - normal is 5-15k during pregnancy RBC 5.8million/mm3 - NO Within range of 5-6.25million for pregnancy. Hematocrit 34% - NO - greater than 33% is fine. - correct answer ✔✔Hemoglobin 10g/dL A nurse is assessing a 16 hr old newborn. Which of the findings should the nurse report to the provider? Substernal Retractions - This, alongside apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection OR respiratory distress in newborns and should be reported IMMEDIATELY. Acrocyanosis - Expected finding for the first 24 hours of birth, this is the blueish hue/tinge to extremities. Overlapping Suture Lines - This is an expected finding. Head Circumference - 33cm/13in. - WITHIN RANGE - correct answer ✔✔Substernal Retractions A Nurse is assessing a late preterm newborn. Which of the following mainfestations is an indication of hypoglycemia? Hypertonia - NO - HYPOtonia. Increased Feedings - NO - Low blood sugar newborns will exhibit POOR feeding behaviors. Hyperthermia - NO - They will have HYPOthermia. Respiratory Distress - YES - Alongside jitteriness, lethargy, poor feeding, apnea, seizures, and an abnormal cry. - correct answer ✔✔Respiratory distress. A nurse is assessing a client who gave birth vaginally 12 hours ago and palpate her uterus to the right above the umbilicus. Which of the following intervention should the nurse perform? Reassess in 2 hours? NO, you should be assessing more frequently. Administer Simethicone? NO - This med is for gassiness. Assist the client to empty their bladder? YES - The findings indicate the client's bladder is distended. This can prevent the uterus from contracting and can result in postpartum hemorrhage. Lie on their right side. No. This will do nothing to resolve the displaced uterus. - correct answer ✔✔Assist the client to empty their bladder. A nurse is caring for a newborn who is undergoing photo therapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Feed the newborn 1 oz of water every 4 hr? No - Water (nor glucose water) increase the excretion rate of bilirubin. Hydration is maintained through regular breastfeeding or formula feeding. Apply lotion to the newborn's skin three times per day. NO - During phototherapy the baby should not have ANY lotions, ointments, creams applied to their skin as this can lead to burns. Remove all clothing from the newborn except the diaper. YES - Maximum skin exposure to the UV light is needed to break down the excess bililrubin. You'll want to ensure the babies eyes are protected, however! Discontinue if the newborn develops a rash? No - a temporary rash CAN occur during therapy and requires no treatment. - correct answer ✔✔ A nurse is planning care for a client who is to undergo a nonstress test. Which of the following should the nurse include in the plan of care? Maintain NPO throughout procedure? NO - Clients are often encourage to drink liquids to promote adequate hydration. Place the client in a supine position? NO - They should be in a SITTING position or a Semi-Fowlers position and TILTED to promote uterine perfusion. Instruct the client to massage the abdomen to stimulate fetal movement? NO - This doesn't do anything for fetal movement. Swelling of the face - YES - Signs of preeclampsia include swelling of the face, sacral area, and fingers. Varicose Veins in the calves - Expected finding. Nonpitting 1+ ankle edema - Expected finding int he third trimester. Hyperpigmentation of the cheeks, areola, vulva, and linea nigra - Expected findings. - correct answer ✔✔Swelling of the face A nurse is assessing a newborn who was born at 26 weeks gestation. Using the New Ballard Score which of the following findings should the nurse expect? Minimal arm recoil - Nurse should expect newborn to have HYPOTONIA or minimal arm recoil. Popliteal angle of 90 degrees - Sign of MATURITY in a newborn, expected after 26 weeks. Creases over the entire foot - Signs of maturity increasing over the term of a fetus. Raised aureoles with 3 to 4 mm buds - Sign of maturity. - correct answer ✔✔Minimal arm recoil - Nurse should expect newborn to have HYPOTONIA or minimal arm recoil. A nurse is caring for a client who is in labor and reports increasing rectal pressure she's experiencing contractions 2 to 3 minutes apart each lasting 80 to 90 seconds in a vaginal examination reveals in her cervix is dilated to 9 cm the nurse should identify that the client is in which of the following phases of labor? Passive descent - The CALM and REST phase. Active - Characterized by cervical dilation between 6-10cm, contractions every 1.5-5m, and lasting 40-90 seconds. Early - 0-5cm, contractions every 2-30min, lasting 30-40 seconds. Descent - Active pushing phase - 1-2 min per contractions lasting 90 seconds. - correct answer ✔✔Active A nurse in a clinic is caring for a 16-year-old adolescent.History and PhysicalAdolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus. Which should the Nurse report? - correct answer ✔✔Abdominal assessment - The pain is NOT an expected finding in a normal, healthy 16 yo. Vaginal Discharge - Greenish discharge indicates an infection. Temperature - Febrile, thus indication of infection or inflammation. Dyspaerunia - Painful intercourse or urination can be associated with STI's. Condom Usage - Sexual activity without condoms increases the risk of contracting STI's. For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process. PID + C-Reactive protein The nurse should expect prescription of Ceftriaxone and Doxycycline - Strong Anti-Biotics. Rest are Anti- fungal or Anti-Virals. Provide patient education and provide Ceftriaxone NOW. - correct answer ✔✔Abdominal Pain - GONORRHEA. Greenish Discharge - Trichomoniasis and Gonorrhea. Diabetes - Candidias - Diabetes predisposes patients to yeast infections. Pain on urination - Trichomoniasis, Gonorrhea, and Candidiasis. Absence of Condom Use - Trichomoniasis and Gonorrhea A nurse is reviewing the medical record for a newly admitted client who is 32 weeks gestation. Which of the following conditions is an indication for fetal heart rate monitoring? Oligohydramnois - YES - Along with other things such as preeclampsia, IUG Restriction, Renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, SLE (Lupus), intrahepatic cholestasis. Hyperemesis Gravidarum - Nope. Leukorrhea - White-ish discharge is common during pregnancy. Periodic Tingling - Common occurrence during pregnancy. - correct answer ✔✔Oligohydramnois A nurse on the postpartum unit is caring for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following assessment findings should the nurse expect to find? ITP is an autoimmune response that results in a decreased platelet count. Increased Erythrocyte Sedimentation Rate - This is a sign of CHRONIC RENAL FAILURE. Decreased Megakaryocytes - Not a sign of ITP. Increased WBC - Not a sign of ITP, this is a sign of infection. - correct answer ✔✔Decreased platelet count A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature- You do monitor for an infection post amniocentesis but FIRST do FHR. Observe the uterine contractions- Yes - but FIRST do FHR. Administer Rho(D) immune globulin- You WILL do this, but FIRST start FHR. Monitor the FHR - The greatest risk of an amniocentesis is the death of the fetus. - correct answer ✔✔Monitor the FHR A nurse is preparing to perform Leopold's Maneuvers for a client identify the sequence the nurse should follow? - correct answer ✔✔Palpate the funds to identify the fetal partDetermine the location of the fetal backPalpate for the fetal part presenting at the inletIdentify the altitude of the head A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? A) administer aspirin for pain B) maintain the client on bed rest - Lowers the risk of dislodging the clot. C) massage the affected leg every 12hr A school nurse is providing teaching to an adolescent about levonorgestrel contraception which of the following information should the nurse include in the teaching? - correct answer ✔✔You should take the medication within 72 hours following unprotected sexual intercourse. A nurse is planning care for a client who is in labor and is to have an amniotomy which of the following assessments for the nurse identify as a priority? TEMPERATURE - The GREATEST risk of an amniotomy is INFECTION. - correct answer ✔✔Temperature A nurse on a antepartum unit is caring for four clients which of the following client to the nurse identify as a priority? A client at 34 weeks of gestation and reports epigatric pain - this patient is exhibiting signs of preeclampsia and indicates hepatic involvement. - correct answer ✔✔A client at 34 weeks of gestation and reports epigatric pain A nurse is assessing a newborn following circumcision which of the following findings should the nurse identify as an indication of the newborn is experiencing pain? Chin quivering - Could also be grimacing, brow furrowing. - correct answer ✔✔Chin quivering A nurse is caring for a client who becomes unresponsive upon delivery of the placenta which of the following actions should the nurse take first. ABC's! - correct answer ✔✔Determine Respiratory Function A nurse is caring for a client following an amniocentesis at 18 weeks of gestation which of the following findings should the nurse report to the provider is a potential complication? - correct answer ✔✔Leakage from the vagina A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). What action should the nurse take ? - correct answer ✔✔Schedule an ultrasound examination - this is done to detect possible development of fetal hydrops. A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next? - correct answer ✔✔Administer oxygen via a nonrebreather mask - REMEMBER the ABC's - all the other choices are correct, but priority is A! A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? - correct answer ✔✔"I will have blood tests because my potassium might decrease." - Adverse effects of terbutaline are hypokalemia + hypotension + hyperglycemia. Given every 4 hr SC but not longer than 24 hr. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? - correct answer ✔✔"I can administer oxytocin 4 hours after the insertion of the medication" A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? - correct answer ✔✔Blurred vision A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? - correct answer ✔✔Reports increased urinary output. Will also potentially have nausea, vomitting, abdominal pain, constipation, drowsiness, and headaches. Fruity breath odor, positive sugar/acetone in urine, and high blood glucose. Caring for a patient at the end of their first trimester, where should the nurse place the Doppler Ultrasound stethoscope in what location? - correct answer ✔✔Just above the symphysis pubis. At the end of the first trimester of pregnancy the client's uterus is about the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? - correct answer ✔✔Demonstrate to the client how to perform a newborn bath. During the "taking-hold" phase they become more focused on becoming a parent and learning new skills. A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? - correct answer ✔✔Left Lower Quadrant A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? - correct answer ✔✔Unilateral Breast Pain - Could be a sign of mastitis. 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? - correct answer ✔✔"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen" "Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen" - correct answer ✔✔Kleihauer-Betke test - This will determine if fetal blood is in maternal circulation. A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? - correct answer ✔✔Hypertension - It's a vasoconstrictor that can cause hypertension but will also prevent bleeding out.