ATI Maternal Newborn Assessment: Questions and Answers, Exams of Nursing

Download ATI Maternal Newborn Assessment: Questions and Answers and more Exams Nursing in PDF only on Docsity!

ATI Maternal newborn assessment A

questions and answers 2023 to 2024

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 - b. amount of lochia 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 - a. apply sacral counter pressure 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 - a. wipe the newborn's eyes from inner canthus outward c. wash the newborn's neck by lifting the newborn's chin

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 - 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 - 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

d. slowed respirations - 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 - 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 - 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.

b. perform the Leopold maneuver c. complete a sterile speculum exam d. prepare a nitrazine paper test - 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 - 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 - 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. 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 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 - 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 yo - 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?

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 - 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 - 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 - d. dry the newborn

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). 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 Prog - 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 - 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?