ATI RN MATERNAL NEWBORN ONLINE PRACTICE 2019 A, RN MATERNAL NEWBORN ONLINE PRACTICE 2019 B, Exams of Advanced Education

Download ATI RN MATERNAL NEWBORN ONLINE PRACTICE 2019 A, RN MATERNAL NEWBORN ONLINE PRACTICE 2019 B and more Exams Advanced Education in PDF only on Docsity!

ATI RN MATERNAL NEWBORN ONLINE

PRACTICE 2019 A, RN MATERNAL NEWBORN

ONLINE PRACTICE 2019 B - ATI

A nurse in an antepartum 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? 1-Hr Glucose Tolerance Test - 120 mg/dL Hematocrit - 34% Fundal Height Measurement - 30 cm Fetal Heart Rate - 110 bpm - Fundal Height 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. 1-Hr GTT of 130-140 or greater indicates a need to report to provider. Hematocrit above 33% is normal FHR is normal (110-160/min) A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed - RR 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Flushing and nausea are expected, but oliguria (levels of 25-30 mL/hr or less) is a sign of toxicity. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice

Caput succedaneum - Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Everything else is expected A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurses priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring. - Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse (this is a common test question--Remember, cord compression is associated with variable decelerations and can happen after ROM). The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. Other actions are correct, but not priority. A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (select all that apply) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible - Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. INCORRECT: Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior

fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record. - Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band. A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions - A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider. All other findings are expected A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? 2+ deep tendon reflexes Proteinuria of 200 mg in a 24-hr specimen Polyuria Blurred vision - Blurred vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. DTR would be 3-4+ Proteinuria would be > Oliguria, not polyuria

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. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR. - Monitor FHR The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. Others are correct, but not priority. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via an IV continuous infusion. Which of the following interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. Restrict the total hourly intake to 200 mL. Monitor the FHR continuously. Administer protamine sulfate for manifestations of toxicity. - Monitor FHR Continuously Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate. The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min. The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema. The nurse should administer calcium gluconate if the client shows manifestations of magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory depression, slurred speech, and cardiac arrest. A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds - Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.

Magnesium sulfate 2g/hr. Available is 20g mag sulfate in 500mL D5W. Set IV to how many mL/hr? - 50 (Desired amount x quantity mL) / Have (2 x 500 / 20) A nurse is assessing a newborn who is 16 hr old. Which of the following finding should the nurse report to the provider? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in) - The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress - Respiratory Distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which action should the nurse take? Administer penicillin G 2.4 million units IM to the client. Instruct the client to schedule an annual pelvic examination. Tell the client she will start medication for HIV immediately after delivery. Report the client's condition to the local health department. - The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? - Have the client change position. Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? Report of visual disturbances Report of tingling of the fingers Report of urinary frequency Report of leg cramps - Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed. A nurse is reviewing prenatal lab results for a client who is at 12 weeks gestation following an initial prenatal visit. Which of the following lab findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 10,000/mm Platelets 250,000/mm Fasting blood glucose 90 mg/dL - A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia. 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 adverse effect of this medication? Depression Polyuria Hypotension Urticaria - The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. Nurse is performing a vag exam on a patient who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which action should the nurse take? Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. Wrap the visible cord tightly with sterile, dry gauze. Apply oxygen to the client at 2 L/min via nasal cannula. Place the client in the lithotomy position and apply fundal pressure. - Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.

The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. Nurse caring for patient who has uterine atony and is experiencing postpartum hemorrhage. Which action is the nurse's priority? Check the client's capillary refill. Massage the client's fundus. Insert an indwelling urinary catheter for the client. Prepare the client for a blood transfusion. - Massage the Client's Fundus Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss. A nurse is caring for a patient that's 32 weeks gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? Excessive bleeding Oligohydramnios Premature rupture of membranes Proteinuria - Premature rupture of membranes- The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction. Oligohydramnios is a decrease in amniotic fluid and is associated with congenital anomalies such as renal agenesis and intrauterine growth restriction. Proteinuria is associated with preeclampsia. Nurse is providing teachings to patient about physiological changes that occur during pregnancy. patient is 10 weeks gestation and has BMI WNL. Which statement indicates an understanding of teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." "I will likely need to use alternative positions for sexual intercourse." "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." "I'm glad I have a light complexion and will not get any stretch marks." - "I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.

Nurse is giving teaching about non-pharmacological pain management to a patient who's breastfeeding and has engorgement. Nurse should recommend application of which items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells - Cold Cabbage Leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply. Nurse is demonstrating how to bathe their newborn. Which order should the nurse perform actions? - The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area. Nurse is caring for a patient who's 36 weeks gestation and has a prescription for amniocentesis. For which reasons should the nurse prepare the patient for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies - To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus. A nurse is caring for a patient who is at 38 weeks of gestation. Which action should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test. - The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.

Nurse caring for patient who's experiencing preeclampsia and has a new prescription for IV mag sulfate. Which med should the nurse anticipate administering if client develops mag toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine - Clacium gluconate is the antidote for mag toxicity. Nurse is performing routine assessment on patient that's 18 weeks gestation. Which finding should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min - FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse. Nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which finding should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas - Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. Nurse is assessing patient who received carboprost for postpartum hemorrhage. Which finding is an adverse effect of this med? Hypertension Hypothermia Constipation Muscle weakness - Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension. Nurse is providing teaching to patient that's 40 weeks gestation and has new prescription for misoprostol. Which instructions should the nurse include in teaching? "I can administer oxytocin 4 hours after the insertion of the medication." "You will need a full bladder prior to the insertion of the medication."

"Remain in a side-lying position for 15 minutes after the medication is inserted." "An antacid will be given 20 minutes prior to the insertion of the medication." - "I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor. Nurse observing a new parent caring for crying newborn who is bottle feeding. Which action by patent should the nurse recognize as a positive parenting behavior? Lays the newborn across her lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in formula Prepares a bottle of formula mixed with rice cereal - Lays the newborn across her lap and gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. Nurse is assessing four newborns. Which of the following findings should the nurse report to HCP? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) - A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week - A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of 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.

A nurse is caring for a client who's 26 weeks gestation and has epilepsy. The nurse enters the room and observes the patient having a seizure. After turning patient's head to one side, which action should the nurse take immediately after the seizure? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids. - Administer oxygen via a nonrebreather mask. (ABCs!) Nurse is assessing patient who's receiving morphine via IV bolus for pain following C- section. Nurse notes RR of 8/min. Which med should the nurse administer? - Naloxone Nurse is teaching patient of 37 weeks gestation and has a prescription for a nonstress test. Which instructions should the nurse include? "The test should take 10 to 15 minutes to complete." "You will lay in a supine position throughout the test." "You should not eat or drink for 2 hours before the test." "You should press the handheld button when you feel your baby move." - "You should press the handheld button when you feel your baby move." The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive. Nurse is assessing patient who's 1 day postpartum and has vaginal hematoma. Which manifestation should nurse expect? Lochia serosa vaginal drainage Vaginal pressure Intermittent vaginal pain Yellow exudate vaginal drainage - Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues. Nurse is caring for a patient who has hyperemesis gravidarum and is receiving IV fluid replacement. Which finding should the nurse report to HCP? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones - BUN 25 mg/dL Indicates dehydration

Nurse is admitting a patient who's in labor. Patient admits to cocaine use. For which of the following complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia - Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta. Nurse is teaching newly licensed nurse about collecting a specimen for universal newborn screening. Which statement should the nurse include in teaching? "Obtain an informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes." - "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing. A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor - Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Nurse is preparing to collect blood specimen from a newborn via heel stick. Which technique should the nurse use to help minimize pain of procedure for newborn? Apply a cool pack for 10 min to the heel prior to the puncture. Request a prescription for IM analgesic. Use a manual lance blade to pierce the skin. Place the newborn skin to skin on the mother's chest. - Place the newborn skin to skin on the mother's chest.

Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure. Nurse is caring for prenatal patient with parvovirus B19 (5th disease). Which action should the nurse take? Administer antiviral medication. Schedule an ultrasound examination. Administer Haemophilus influenzae type b vaccine. Schedule an indirect Coombs' test. - Schedule an ultrasound examination. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. Nurse is developing POC for newborn undergoing phototherapy for hyperbilirubinemia. Which action should the nurse include in plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash. - Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. Nurse is providing education about family bonding to patents who recently adopted a newborn. Nurse should make which suggestion to aid family's 7 y/o child in accepting the new family member? Allow the sibling to hold the newborn during a bath. Make sure the sibling kisses the newborn each night. Obtain a gift from the newborn to present to the sibling. Switch the sibling's room with the nursery. - Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. Nurse is caring for patient that's 24 weeks gestation and has suspected placental abruption. Which lab test should the nurse expect the HCP to prescribe? Kleihauer-Betke test Progesterone serum level

Lecithin/sphingomyelin (L/S) ratio Maternal Alpha-fetoprotein (AFP) - Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative. Nurse providing discharge teaching to patient with c-section 3 days ago. Which instructions should the nurse include? "You can resume sexual activity in 1 week." "You won't need to do Kegel exercises since you had a cesarean." "You can still become pregnant if you are breastfeeding." "You are safe to start adding sit-ups to your exercise routine in 2 weeks." - "You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding. Nurse is assessing a patient with GDM and experiencing hyperglycemia. Which finding should the nurse expect? Reports increased urinary output Diaphoresis Reports blurred vision Shallow respirations - Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL. Nurse in a provider's office is reviewing the medical record of a client who is in the 1st trimester of pregnancy. Which finding should the nurse identify as a risk factor for development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus - Pregestational diabetes mellitus Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

Nurse creating a POC for patient who's postpartum and adheres to traditional Hispanic cultural beliefs. Which cultural practice should the nurse include in POC? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal. - Protect head and feet from cold air. Traditional hispanic practice. Nurse caring for patient who's anemic at 32 weeks gestation and in preterm labor. HCP prescribes betamethasone 12 mg IM. Which outcome should nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn - A reduction in respiratory distress in the newborn Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. Nurse is giving teaching to patient who gave birth 2 hrs ago about facility policy for newborn safety. Which patient statement indicates an understanding of teaching? "My sister will be able to carry my baby from the nursery to my room when she arrives." "The nurse will match my wrist band to my baby's crib card when they bring him to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when he's in my room." - "The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn. First Step of Leopold's Maneuvers - During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus. Nurse teaching the patient that's 10 weeks gestation about nutrition during pregnancy. Which statement by patient indicates an understanding of teaching?

"I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day." - "I should take 600 micrograms of folic acid each day." A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. Nurse in an antepartum clinic is assessing a patient that's 32 weeks gestation. Which finding should the nurse report to HCP? Fundal height 34 cm Report of decreased fetal movement Report of occasional ankle swelling BP 110/80 mm Hg - The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress. Nurse performing physical assessment of a newborn. Which of the following clinical findings should the nurse expect? Heart rate 154/min Axillary temperature 36° C (96.8° F) Respiratory rate 58/min Length 43 cm (16.9 in) Weight 2,600 g (5 lb 12 oz) - Heart rate 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. Respiratory rate 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb). Axillary temperature 36° C (96.8° F) is incorrect. 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). Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). Nurse is caring for a postpartum patient who is receiving heparin via continuous IV infusion for thrombophlebitis in left calf. Which action should the nurse take? Administer aspirin for pain. Maintain the client on bed rest. Massage the affected leg every 12 hr. Apply cold compresses to the affected calf. - Maintain the client on bed rest.

The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. Nurse is caring for a client who's 36 weeks gestation and has a positive CST. The nurse should plan to prepare client for which dx test? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test - Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider? - Shortness of breath A. Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. 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 as a potential complication? - Leakage of fluid from the vagina B. Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? - Answer: September 3rd A. September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? - Answer: Biophysical profile (BPP) C. Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? - Answer: "You can share your room with your baby for the next few weeks." A. "You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. 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 8 cm and reports back pain. Which of the following actions should the nurse take? - Answer: Apply sacral counterpressure. A. Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? - Answer: Cover the newborn's eyes while under the phototherapy light. A. Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? - Answer: Apply internal upward pressure to the presenting part using two gloved fingers. B. Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying

upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand. 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? (SATA) - Answer: Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? - Answer: "Staff members who take care of your baby will be wearing a photo identification badge." D. "Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs. A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? - Answer: Vomiting D. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Answer: Vomiting 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? - Answer: Left lower quadrant A. Left upper quadrant The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. B. Right upper quadrant The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. C. Left lower quadrant

The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. D. Right lower quadrant The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant. A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? - Answer: Stop suctioning when the newborn's cry sounds clear. D. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. 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? - Answer: Platelets 50,000/mm 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 nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta? - A. The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area. Answer: A A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? - Answer: A client who is at 34 weeks of gestation and reports epigastric pain B. A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicated an understanding of the teaching? - Answer: "I will eat foods that taste good instead of balancing my meals."

A. "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. 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? - Answer: Demonstrate to the client how to perform a newborn bath. D. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking- hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment. A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? - Answer: Swelling of the face A. Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? - Answer: Jitteriness A. Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. 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? - Answer: "I will have blood tests because my potassium might decrease." A. "I will get injections of the medication once daily until my labor stops." Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. B. "My blood sugar may be low while I'm on this medication." An adverse effect of terbutaline is hyperglycemia. C. "I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia.

D. "My blood pressure may increase while I'm on this medication." An adverse effect of terbutaline is hypotension. A nurse is planning care for a client who is in labor and is having an amniotomy. Which of the following assessments should the nurse identify as the priority? - Answer: Temperature B. Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. 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? - Answer: Apply cabbage leaves to the breasts. B. Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. 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? - Answer: Determine respiratory function. A. Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? - Answer: "I will continue taking my insulin if I experience nausea and vomiting." C. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? - Answer: Chin quivering B. Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interperate the client's statement as an indication of which of the following? - Answer: Emotional lability A. Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives? (SATA) - Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives. A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? - Answer: "You should take the medication within 72 hours following unprotected sexual intercourse." A. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? - Answer: Place the retainer clip at the level of the newborn's armpits. B. Place the retainer clip at the level of the newborn's armpits.

The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

• Answer: The nurse should have calcium gluconate readily available B. Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) - The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head. A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? - Answer: Headache that is unrelieved by analgesia C. Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. 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? - Answer: Massage the client's fundus. 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. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? - Answer: Just above the symphysis pubis B. Just above the symphysis pubis

At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? - Answer: "You will be offered orange juice to drink during the test." C. "You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results. 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? - Answer: Instruct the client to press the provided button each time fetal movement is detected. 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 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? - Answer: "You can miss your period for several other reasons. Describe your typical menstrual cycle." A. "You can miss your 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. A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? - Answer: Explain to the client this is an expected occurrence. B. Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.