RNN VATI Maternal Newborn 2019 Assessment with all Q&A/ RN Vati Maternal Newborn 2019, Exams of Nursing

Download RNN VATI Maternal Newborn 2019 Assessment with all Q&A/ RN Vati Maternal Newborn 2019 and more Exams Nursing in PDF only on Docsity! RNN VATI Maternal Newborn 2019 Assessment with all Q&A/ RN Vati Maternal Newborn 2019 Quiz Updated 2023-2024 A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of the following findings should the nurse identify as a risk factor for developing preeclampsia? -------- Correct Answer --------- Rheumatoid Arthritis. -The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus erythematosus, increase a clients risk for developing preeclampsia. A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor? -------- Correct Answer --------- International normalized ratio (INR). -The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time(PT) is also measure to regulate warfarin therapy. However, PT values are more difficult to interpret. INR determined by multiplying the PT by a correction factor based on the specific thromboplastin preparation used for the test, as a way of equalizing laboratory to laboratory variations. A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching? -------- Correct Answer --------- I can breastfeed my baby even though I received this immunization. -According to the CDC, breastfeeding should not delay a client from receiving the rubella immunization. A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the provider? -------- Correct Answer --------- Generalized petechiae -Are pinpoint round spots that appear on the skin, which can indicate a clotting factor deficiency or infection. A nurse is preparing to administer methotrexate 1 mg/kg IM to a client who weights 110lbs and is receiving care for an ectopic pregnancy. Available is methotrexate 25 mg/mL. How many mL should the nurse administer? -------- Correct Answer --------- 2 A nurse is caring for a 2 day old newborn who has a bilirubin level of 14 mg/dL and is to begin phototherapy. Which of the following actions should the nurse take? -------- Correct Answer --------- Monitor intake and output. -The nurse should monitor intake and output because phototherapy can increase the rate of insensible water loss, which contributes to fluid loss and dehydration. The nurse should also monitor the newborns fontanels. Hydration is achieved by breastfeeding or formula feeding the newborn. A nurse is monitoring a client who is receiving oxytocin to augment labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following actions is the nurse's priority? -------- Correct Answer --------- Position the client laterally. -Late decelerations occur because of uteroplacental insufficiency. First position the client in a lateral position to improve oxygenation to the fetus. A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective? -------- Correct Answer --------- Respiratory rate 12/min -Respiratory depression is a manifestation of magnesium sulfate toxicity. A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain? -------- Correct Answer --------- Encourage the client to listen to music -The nurse should implement nonpharmacological strategies to encourage relaxation and provide pain relief. There are a wide variety of cutaneous and sensory measures that are simple to implement during this stage of labor, such as music, rocking, breathing techniques, walking and application of hot and cold packs. A nurse is providing discharge instructions to the parents of a newborn about bathing. Which of the following statements by the parent indicates an understanding of the instructions? -------- Correct Answer --------- We will wash out newborn's face first. -Bathing should proceed from the cleanest part of the body to the most soiled areas. First, from the eyes and face, then to the trunk and extremities, and then to the diaper area to prevent the spread of infection or cross contamination. A nurse is interviewing a client who is at 10wks of gestation. Which of the following statements by the client should the nurse investigate further? -------- Correct Answer ---- ----- I just want to stay in bed all day because nothing interest me anymore. -Feelings of sadness marked by loss of interest in usual activities can indicate depression, which is not a normal adaptation to pregnancy. A nurse is planning to use a Doppler device to auscultate fetal heart tones (FHTs) for a client who is at 12wks of gestation. Which of the following actions should the nurse plan to take? -------- Correct Answer --------- Count the radial pulse of the client while auscultating FHTs. -The nurse should count the client's radial pulse while auscultating FHTs to differentiate it from the fetal heart rate. A nurse is providing teaching for a guardian regarding newborn care. Which of the following statements by the guardian indicates understanding of the teaching? -------- Correct Answer --------- I will use a rear-facing car seat for my baby for the first 2 years. -Infants should travel in rear-facing car seats until the age of 2 years old or until the child reaches the height or weight requirements that are recommended by the manufacturer of the care seat. -Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased perfusion to the retina cause visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. A nurse is assessing a client who is at 8wks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (SATA) -------- Correct Answer --------- 1. Tachycardia. -Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte imbalance, excessive weight loss, ketonuria, and nutritional deficiencies. 2. Dry mucous membranes. 3. Poor skin turgor. A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse identify as an indication of a prenatal complication? -------- Correct Answer --------- BUN 30 mg/dL -Above the expected reference range of 10-20 mg/dL for a client who is pregnant. The BUN typically decreases during pregnancy due to the increase in the glomerular filtration rate. The nurse should identify that an elevated BUN is a manifestation of preeclampsia or HELLP syndrome, potentially serous complications of pregnancy's. A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad in 15min. The clients skin is cool and clammy to touch. Which of the following actions should the nurse take first? -------- Correct Answer --------- Firmly massage the fundus. -The greatest risk for a postpartum client who is experiencing excessive vaginal bleeding is the development of hypovolemic shock, which can lead to coma and death. Uterine atony is a frequent cause of excessive vaginal bleeding. Therefore, the first action the nurse should take is to massage the clients fundus to encourage muscular contractions, which will decrease bleeding. A nurse is caring for a client who is at 28wks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider? -------- Correct Answer --------- Heart rate: 132/min -The nurse should notify the provider of tachycardia greater than 130/min; therefore, this is the priority finding. The client might also report chest discomfort, palpitations and have arrhythmias. A nurse is providing teaching for a client who is 2wks postpartum and has mastitis. Which of the following instructions should the nurse include in the teaching? -------- Correct Answer --------- Apply moist heat to the affected breast. -The application of warm compresses prior to feeding or pumping promotes the flow of the breast milk and assists to ensure complete emptying of the breast. This is important to prevent the development of further complications such as the formation of a breast abscess or chronic mastitis. A nurse is teaching routine prenatal care to a group of clients who are pregnant. Which of the following statements by a client indicates an understanding of the teaching? ------- - Correct Answer --------- I will have monthly prenatal visits for the first 28wks of pregnancy. -The initial visit should occur in the first trimester with monthly visits through week 28, and every 2 weeks until week 36, and then every week until the birth of the newborn. A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the following statements should the nurse include in the teaching? (SATA) -------- Correct Answer --------- 1. You might have to have cultures for sexually transmitted infections prior to placement of the device. -If the provider determines the client is at risk of STI they might require the collection of cultures for STI prior to the placement of the IUD. 2. You might experience irregular spotting the first few months after placement of the device. 3. You will need to sign informed consent prior to the procedure. A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse report to the provider? -------- Correct Answer --------- Epigastric pain. -This is a manifestation of preeclampsia. Other findings the nurse should report include severe HA, Blurred vision, confusion, N&V, and decrease urinary output. A nurse is assessing a client who is 6hrs postpartum, tachycardia, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take? -------- Correct Answer --------- Initiate and infusion of oxytocin. -The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which can be caused by uterine atony and is a medical emergency. The nurse should initiate an infusion of 10-20 units of oxytocin, which is an oxytocic medication. This will cause the uterus to contract and decrease bleeding. A nurse is monitoring a client who is in active labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following findings should the nurse recognize as the potential cause of the deceleration? -------- Correct Answer ------- -- Fetal hypoxia -Late decelerations are caused by uteroplacental insufficiency or a decreased blood flow from the uterus to the placenta during contractions. This results in a decreased supply of oxygen to the fetus during the contraction. This pattern can be cause by a wide variety of reasons including uterine tone, maternal hypotension, and disorders that affect the placenta such as maternal diabetes, preeclampsia and post maturity. A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching? -------- Correct Answer --------- The patent should plan to spend individual time with the older sibling. -To enhance and facilitate sibling acceptance of the newborn. A nurse is caring for a newborn immediately following birth who has meconium-stained amniotic fluid and exhibits good muscle tone and respiratory efforts. Which of the following actions should the nurse take first? -------- Correct Answer --------- Begin suctioning of mouth and nose. -The nurse should assess the newborns' condition at birth and suction the newborn's mouth and nose with a bulb syringe based on the assessment findings. If the newborns respiratory status is depressed, endotracheal suctions must be done as well to remove any meconium that has entered the newborn's airways. A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching? -------- Correct Answer --------- I will be certain to consume 29 grams of fiber daily. -The client should consume a diet high in fiber and increase fluid intake to help reduce the occurrence of constipation. A nurse is performing a contraction stress test (CST) on a client who is at 40wks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take? -------- Correct Answer --------- Allow the labor to progress naturally. -The absence of late deceleration (a negative results) indicates that the fetus will probably tolerate labor; therefore, the nurse should allow the labor to progress naturally. A nurse is caring for a newborn who was delivered by cesarean birth 1 min ago and displays some flexion of the extremities, is not cry, has irregular respiratory effort, and has a heart rate of 92/min. The nurse notes grimacing but no crying when rubbing the soles of the newborn's feet. The newborn's skin color is pink with blue extremities. What is the correct Apgar score? -------- Correct Answer --------- 1 min is 5. A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level in the abdomen a nurse should expect to find the client's uterus when assessing the fundus. -------- Correct Answer --------- C is correct. -Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum. A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. Which of the following actions should the nurse take? -------- Correct Answer --------- Wear two pairs of gloves when handling the medication. -Methotrexate is an antineoplastic agent that a pharmacist must prepare in a syringe under a biologic safety cabinet and place in a sealed plastic bag. The nurse should wear two pairs of gloves when removing the syringe from the bag, administering the medication, and disposing of the syringe. A nurse is caring for a postpartum client who is breastfeeding her newborn and reports that her nipples have become sore and cracked. Which of the following statements should the nurse make? -------- Correct Answer --------- Apply colostrum to the nipples after feeding to help them heal. -Colostrum and breast milk have healing properties and can help reduce soreness. A nurse is receiving report on four newborns born in the past 12hrs. Which of the following newborns should the nurse assess first? -------- Correct Answer --------- A newborn who has an axillary temperature of 36C (96.8F). -Cold stress increases the newborn's need for oxygen and can deplete glucose stores. It also can increase the newborn's respiratory rate and cause cyanosis. The expected axillary temperature for the newborn averages 37C (98.6F) and ranges form 36.5C (97.7F) to 37.2C (99F). A nurse is teaching a new guardian how to correctly use a car seat. Which of the following statements by the guardian indicates an understanding of the teaching? -------- Correct Answer --------- I should keep my baby in a rear-facing car seat until he is 2yrs old. -Or until the child reaches the maximum height and weight for the seat. A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take? -------- Correct Answer --------- Cleanse the puncture site with alcohol gauze prior to the procedure. -Or a facility-approved skin cleanser prior to the procedure to minimize the risk of infection. A nurse is teaching a client who has hyperemesis gravidarum about dietary modifications. Which of the following client statements indicates an understanding of the teaching? -------- Correct Answer --------- I will eat small, frequent meals throughout the day. -The client should focus on eating small, frequent meals throughout the day and consuming foods that are appealing. A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall? -------- Correct Answer --------- A client who has an indwelling urinary catheter. -The client's required medical interventions, such as IVs and urinary catheters, increase the risk for falls from tripping over tubing. The nurse should assist the client when getting out of bed and ambulating to prevent an injury from a fall. A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take? -------- Correct Answer --------- Obtain a vaginal culture. -Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. The nurse should obtain a vaginal culture using a sterile swab to collect the fluid from the client's vaginal cavity to identify the organism. A nurse is caring for a client who is in active labor and receiving epidural anesthesia. The client reports feeling nauseated and experiences a blood pressure drop from 125/70 mm Hg to 90/50 mm Hg. Which of the following actions should the nurse take first? -------- Correct Answer --------- Turn the client to a lateral position. -The greatest risk to this client is injury from maternal hypotension and decreased placental perfusion; therefore, the first action the nurse should take is to place the client in a lateral position to relieve the pressure on the vena cava and restore venous return. A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my baby is breech." Which of the following actions should the nurse take first? -------- Correct Answer --------- Check fetal heart tones. -A variation in fetal heart tones can occur due to a prolapsed umbilical cord. The risk of a prolapsed cord is increased with noncephalic presentations when the membranes are ruptured. Prolapse of the cord compromises circulation to the fetus. A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the clients pain? -------- Correct Answer --------- Encourage the support person to apply sacral counterpressure. -Consistent pressure applied by the support person using the heel of the hand or fist against the client's sacral area will lift the fetal head off the spinal nerves and provide relief of the pain in the lower back. A nurse is caring for a client who had a vaginal delivery 2hrs ago and is reporting increasing perineal pain and pressure. The nurse examines the clients perineum and sees a 4cm (1.6in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following? -------- Correct Answer --------- A hematoma -A hematoma is a collection of blood in the connective tissue while the overlying skin or mucous membranes remain intact. Hematomas develop from injury to soft tissue in spontaneous deliveries, as well as forceps-and-vacuum-assisted deliveries. Small hematomas usually reabsorb on their own, but large ones might require incision and ligation of bleeding vessels. A nurse is providing prenatal education to a client who is at 16wks of gestation. Which of the following statements by the client indicated an understanding of anticipated body changes during the second trimester? -------- Correct Answer --------- I might notice a change in my skin coloring. -Skin pigmentation deepens during the second trimester of pregnancy due to actions of the melanocyte-stimulating hormone. A nurse is providing teaching to a client who is at 8wks of gestation about vaccines that are administered during pregnancy. Which of the following vaccines should the nurse discuss with the client? -------- Correct Answer --------- Tetanus-diphtheira-acellular pertussis (Tdap) vaccine. -The CDC recommends that clients who are pregnant should receive the Tdap and seasonal inactivated influenza vaccine with each pregnancy. Clients who are pregnant should avoid all live or live attenuated immunizations due to potential for teratogenic effects in the fetus. A nurse is collecting information about a health history for a client who requests a prescription for a combined oral contraceptive (COC). Which of the following information should the nurse identify as a contraindication for the use of a COC? -------- Correct Answer --------- History of migraine with aura. -Contain both estrogen and progestin. These hormones can cause an increase in the risk for thrombotic stroke for clients who have migraine w/aura. Safe for client to have migraines without aura to use a COC if they have no other contraindications, such as a history of estrogen-dependent tumors or coronary artery disease. A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. Which of the following actions should the nurse take? -------- Correct Answer --------- Position the client using the McRoberts maneuver. -Decreases shoulder dystocia. The nurse should flex the client's thighs sharply against their abdomen, with their legs apart, to straighten the sacral area and rotate the symphysis pubis toward the client's head. A nurse is assessing a client who is at 32wks of gestation. Which of the following findings is an indication of a potential prenatal complication? -------- Correct Answer ----- ---- Epigastric pain. -Indication of preeclampsia. Other indications of preeclampsia include abdominal pain, severe HA, HTN, polyuria, and proteinuria. A nurse is caring for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following actions should the nurse plan to take? -------- Correct Answer --------- Change the newborn's position every 2hrs. -Reposition the newborn every 2-3hrs during phototherapy. This will maximize exposure of the skin to the light, enhancing the effectiveness of phototherapy. A nurse is creating a plan of care for a client who is at 35wks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following interventions should the nurse include? -------- Correct Answer --------- Initiate continuous monitoring of the FHR. -Initiate continuous monitoring of the FHR and uterine activity using an external fetal monitor. A charge nurse is discussing syphilis with a newly licensed nurse. Which of the following statements should the charge nurse make? -------- Correct Answer --------- A chancre lesion appears within 90 day after infection during the primary stage. -The charge nurse should identify that a chancre is the primary lesion that occurs during a syphilis infection. This lesion appears within 90 days of exposure to the infection and begins as a painless papule, which then erodes into an ulcer.