VATI Maternal Newborn Pre-Assessment Questions and Answers, Exams of Nursing

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VATI Maternal Newborn Pre-Assessment

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A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membranes B. Changes in the cervix C. Station of the presenting part D. Pattern of contractions - Correct answer B. Changes in the cervix Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor. A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.) A. "I'll expect the plastic ring to fall off by itself within a week." B. "I'll apply petroleum jelly to his penis with diaper changes." C. "I'll wash his penis with warm water and mild soap each day." D. "I'll call the doctor if I see any bleeding." E. "I'll make sure his diaper is loose in the front." - Correct answer A. "I'll expect the plastic ring to fall off by itself within a week." D. "I'll call the doctor if I see any bleeding." E. "I'll make sure his diaper is loose in the front." A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? A. Contractions lasting longer than 90 seconds B. Contractions occurring every 3 to 5 min C. Contractions are strong in intensity D. Client reports feeling contractions in lower back - Correct answer A. Contractions lasting longer than 90 seconds A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.

In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min intervals. This is an expected finding. This is an expected finding in a client who is moving from the active to transition phase of the first stage of labor. It does not need to be reported to the provider. This is an expected finding in a client who is in true labor. As the labor progresses, the contractions radiate to the abdomen. A nurse is caring for a client who experienced a vaginal birth 3 hr. ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? A. Massage the fundus B. Insert a urinary catheter C. Have the client urinate D. Administer an analgesic - Correct answer C. Have the client urinate A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine agony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus. A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations? A. "It is used to stop preterm labor contractions." B. "It halts cervical dilation." C. "It promotes fetal lung maturity." D. "It increases the fetal heart rate." - Correct answer C. "It promotes fetal lung maturity." Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant. Magnesium sulfate, not betamethasone, is an example of a tocolytic medication that helps stop preterm labor. A tocolytic medication relaxes the smooth muscles of the uterus to stop preterm labor, and if effective, will also halt cervical dilation. Terbutaline is an example of a tocolytic medication that can cause fetal tachycardia. A nurse is caring for a preterm newborn that is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? A. "Preterm newborns have a smaller body surface area than normal newborns." B. "The added brown fat layer in a preterm newborn reduces his ability to generate heat." C. "Preterm newborns lack adequate temperature control mechanisms."

D. "The heat in the incubator rapidly dries the sweat of preterm newborns." - Correct answer C. "Preterm newborns lack adequate temperature control mechanisms." Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator. Preterm newborns do not sweat. The lack of brown fat stores found in a preterm newborn limits the ability to generate body heat. Preterm newborns have a large body surface area for their weight. A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet? A. Peanut butter B. Potatoes C. Apple juice D. Broccoli - Correct answer A. Peanut butter The nurse should instruct the client to eliminate protein-rich foods that contain phenylalanine from the diet. These include meats, eggs, milk, nuts, and wheat products. A nurse is caring for a client who is at 12 weeks of gestation on an antepartum unit. Client is a 20 years old, gravid 1 Para 0, and at 12 weeks of gestation with twins by serial ultrasound. Admitted for hyperemesis gravid arum. The client reports being severely nauseated and reports vomiting with all meals since being at 8 weeks of gestation. Height 162.56 cm (5 ft. 4 in) Pre-pregnancy weight 55 kg (121 lb.) Blood type O+ Rubella Abs titer: Immune VDRL: NR Hip B: NR Cervical gonorrhea & chlamydia culture: Negative Pap smear: Normal PPD: not done Sick prep: not done HIV test: NR Glucose test: Denies having it done Group B strep: not done Herpes: Denies Seizures: Denies Hip C: NR

Current Medications: Prenatal Vitamins Allergies: Penicillin Day 1 0930 Client admitted to antepartum unit from clinic today with reports of severe nausea and vomiting. Client states they have lost 2.27 kg (5 lb.) in the past week. Day 1 - Correct answer Anticipated:

• Initiate lactated Ringer's IV bolus of 500 mL followed by 150 mL/hr.
• Administer pyridoxine 25 mg every 8 hr. slow IV bolus
• Give ondansetron 4 mg every 6 hr. slow IV bolus, as needed
• Monitor basic metabolic panel
• Diet NPO Contraindicated:
• Give magnesium IV bolus at 4 g/hr.
• Administer terbutaline 0.25 mg SC as needed
• High fat full liquid A nurse is providing teaching about Keel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? A. "These exercises help prevent constipation." B. "These exercises help pelvic muscles to stretch during birth." C. "They can help reduce back aches." D. "They can prevent further stretch marks." - Correct answer B. "These exercises help pelvic muscles to stretch during birth." Keel exercises improve the strength of perinea muscles, facilitating stretching and contracting during childbirth. A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which of the information should the nurse include? A. "This medication will help prevent nausea and vomiting." B. "Your contractions will become stronger and more frequent." C. "I will remove the electronic fetal monitor once contractions are regular." D. "You can push the button on the control device to administer more medication." - Correct answer B. "Your contractions will become stronger and more frequent."

Oxytocin is diluted with sodium chloride and administered IV via an infusion pump device to induce or strengthen uterine contractions during labor. The client who is receiving an oxytocin drip is closely monitored to promote a safe delivery and prevent maternal and/or fetal complications. The desired concentration of oxytocin medication is determined by the desired labor contraction pattern that should increase in frequency, duration, and intensity. The nurse closely monitors risks of continuous IV infusion of oxytocin to determine when to discontinue the medication. Risks include fetal distress (fetal bradycardia) caused by hyper-stimulation of the uterus compromising blood flow to the fetus. Uterine contractions lasting longer than 90 seconds should prompt the nurse to discontinue the medication. A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A. Left lower B. Right lower C. Left upper D. Right upper - Correct answer D. Right upper Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant. A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissue remain in the uterus. How should the nurse document these findings? A. Incomplete miscarriage B. Missed miscarriage C. Inevitable miscarriage D. Complete miscarriage - Correct answer B. Missed miscarriage With a missed miscarriage, the fetus has died but the client retains the products of conception for several weeks. The client might have spotting or no bleeding at all. With an incomplete miscarriage, the client has expelled some, but not all, of the products of conception. With an inevitable miscarriage, the client has moderate to heavy bleeding, cervical dilation, and often, ruptured membranes. With a complete miscarriage, the client has expelled all the products of conception. A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should

anticipate a prescription from the provider for which of the following medication for the client? A. Carbone B. Repaginate C. Glyburide D. Glipizide - Correct answer C. Glyburide With the exception of glyburide, clients who are pregnant do not take oral hypoglycemic because they cross the placenta and can injure the fetus. Approximately 20% of clients who have gestational diabetes mellitus will require insulin. Insulin lowers blood glucose levels without harming the fetus. A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus? A. Calcium B. Iron C. Vitamin C D. Folic acid - Correct answer D. Folic acid Adequate amounts of folic acid before conception and during the first trimester of pregnancy are necessary for fetal neural tube development. This vitamin helps prevent spine bifida and other neurological disorders. A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth." - Correct answer A. "You should place your nipple and some of the areola into her mouth." Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness. A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching? A. "I should limit my carbohydrates to 50% of caloric intake."

B. "I will reduce my exercise schedule to 3 days a week." C. "I will take my glyburide daily with breakfast." D. "I know I am at increased risk to develop type 2 diabetes." - Correct answer B. "I will reduce my exercise schedule to 3 days a week." Increased exercise benefits the client and can result in improved management of gestational diabetes. Carbohydrate intake should be limited to 50% of caloric intake. Glyburide is appropriate for the pregnant client, as minimal amounts cross the placenta. Women with gestational diabetes have a 35% to 60% risk for developing type 2 diabetes within the next 20 years. A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? A. Early decelerations B. Accelerations C. Late decelerations D. Variable decelerations - Correct answer D. Variable decelerations Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus. The usual cause of early decelerations is fetal head compression, such as from uterine contractions or fundal pressure. Accelerations are caused by fetal movement, vaginal examination, electrode application, and fetal scalp stimulation. Late decelerations are caused by insufficient placental perfusion during contractions. This results in a disruption of the flow of oxygen to the fetus. A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? A. Respirations 16/min B. Headache for 30 min C. Urinary output 40 mL in 2 hr. D. Fetal heart rate 158/min - Correct answer C. Urinary output 40 mL in 2 hr. Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr. to the provider immediately and discontinue the medication. A respiratory rate of 16/min is within the expected reference range for a client receiving magnesium sulfate. The acceptable range for respiratory rate is 16 to 20/min. Headaches and muscle weakness are expected reactions to magnesium sulfate

administration. They do not require reporting to the provider. A fetal heart rate of 158/min is within the expected reference range The expected reference range for the fetal heart rate is 110/min to 160/min. A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? A. "Use a natural membrane condom rather than a polyurethane condom." B. "You may use a condom more than once." C. "Use an oil-based lubricant when you use a condom." D. "Female condoms can help prevent transmission of sexually transmitted viruses." - Correct answer D. "Female condoms can help prevent transmission of sexually transmitted viruses." The client who uses a female condom can prevent sexually transmitted viruses when the polyurethane or nitrile sheath is placed in the vagina. The client should use a polyurethane condom instead of a natural membrane condom because natural condoms do not protect the client from HIV infection. The client should use a new condom with every sexual encounter for effective prevention of transmission of an infection and to decrease the risk of breaking or slipping off. The client should not use an oil-based lubricant as the oil can damage the condom. The client should use a water-based lubricant. A nurse is caring for a client who is at 36 weeks of gestation and is on the antepartum unit for continuous close observation. The client confides to the nurse that she doesn't think she will ever be a mother and begins to cry. Which of the following responses should the nurse make? A. Reassure the client that the provider will use advanced medical technology to detect any problems with her pregnancy. B. Sit quietly with the client and follow her cues. C. Suggest that the client discuss her fears with her provider. D. Gently change the subject to something more positive. - Correct answer B. Sit quietly with the client and follow her cues. This demonstrates using silence and active listening, therapeutic techniques that offer support and acceptance and encourage further communication. A nurse in a prenatal clinic is caring for a client who is pregnant and ask the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? - Correct answer 0504

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha- fetoprotein (MSAFP) screening for which of the following clients? A. A client who has mitral valve prolapse B. A client who has been exposed to AIDS C. All of the clients D. A client who has a history of preterm labor - Correct answer C. All of the clients MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman. Pregnancy is usually tolerated well in the client who has mitral valve prolapse. Prophylactic treatment with antibiotics before birth is recommended to prevent bacterial endocarditis. Clients whose behavior places them at a high risk for exposure to the human immunodeficiency virus (HIV) should receive HIV antibody screening testing. The fetal fibronectin (FFN) test is utilized to predict the likelihood that preterm labor and birth will occur. The use of this test as a screening tool in women who are at a low risk for preterm birth is not recommended. A nurse is caring for a client who is postpartum and is breastfeeding. The client states that she is concerned about dietary precautions since she has a family history of food allergies. The nurse offers which of the following responses? A. "You might want to avoid eating peanuts." B. "Rice cereals can be a problem during lactation." C. "Foods you eat do not affect breast milk." D. "The infant needing more sleep can indicate a food allergy." - Correct answer A. "You might want to avoid eating peanuts." There are no standard foods that are contraindicated during breastfeeding. With a family history of food allergies, it is important to avoid eating highly allergenic foods, such as peanuts, as well as other foods to which the client has a known allergy. Common food allergies include wheat products, such as wheat cereal. The flavor of breast milk can be altered by foods and spices in the diet. Colic-like symptoms occur in infants with a family history of milk protein intolerance. Infants who are breastfed can exhibit fussiness and gastrointestinal distress as a response to foods and spices consumed by mothers. A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A. "This will occur during the last trimester of pregnancy." B. "This will happen by the end of the first trimester of pregnancy."

C. "This will occur between the fourth and fifth months of pregnancy." D. "This will happen once the uterus begins to rise out of the pelvis." - Correct answer C. "This will occur between the fourth and fifth months of pregnancy." Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks. A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? A. Assess deep tendon reflexes every hour. B. Obtain a daily weight. C. Continuous fetal monitoring D. Ambulate twice daily. - Correct answer D. Ambulate twice daily. A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bed rest in a quiet, no stimulating environment to prevent seizures and promote optimal placental blood flow. A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use? A. The client is 42 years old. B. The client smokes cigarettes. C. The client has pelvic relaxation. D. The client has a 3-month-old infant. - Correct answer C. The client has pelvic relaxation. Pelvic relaxation and large cystocele are contraindications for diaphragm use. Age is not a contraindication to the use of a diaphragm. Cigarette smoking is not a contraindication to the use of a diaphragm. Pregnancy changes the size and shape of the cervical opening, which will affect the fit of the diaphragm. The uterus and cervix returns to the prep regnant state at 6 weeks postpartum. At this time, the client should consider being refitted for a diaphragm to resume sexual activity. The diaphragm is contraindicated immediately after pregnancy to allow healing and avoid infection. A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) A. Administer magnesium sulfate IV. B. Provide a dark, quiet environment. C. Assess respiratory status every 4 hr. D. Evaluate neurologic status every 8 hr.

E. Ensure that calcium glucometer is readily available. - Correct answer A. Administer magnesium sulfate IV. B. Provide a dark, quiet environment. E. Ensure that calcium glucometer is readily available. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 me/L. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. Calcium glucometer is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress. A nurse is caring for a client during a no stress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15/min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? A. A negative test B. A nonreactive test C. A positive test D. A reactive test - Correct answer B. A nonreactive test An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds. A negative test is one of the findings for a client having a contraction stress test (CST). This result indicates that at least three uterine contractions occurred in a 10-min period with no late or significant variable decelerations. A positive test is one of the findings for a client having a contraction stress test (CST). This result indicates that late decelerations occurred with 50% or more of the contractions, even if fewer than three contractions occurred in a 10-min period. An NST is interpreted as reactive if the fetus has a minimum of two accelerations in a 20-min period, each lasting at least 15 seconds and peaking at least 15/min above the FHR baseline. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A. Placenta prevail B. Prolapsed cord C. Incompetent cervix D. Abruption placentae - Correct answer D. Abruption placentae The classic signs of abruption placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. Placenta prevail occurs with painless vaginal bleeding during the second and third trimester. A prolapsed umbilical cord occurs when the cord lies below the presenting fetal part. It might be visible or palpable with a vaginal exam. There might be changes to the fetal heart rate tracing. An incompetent cervix is a cause of late miscarriage. It results in painless, passive dilation of the cervix during the second trimester of pregnancy. A nurse is caring for a client following an anatomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. Maintain the client in the lithotomy position. B. Perform vaginal examinations frequently. C. Remind the client to bear down with each contraction. D. Encourage the client to empty her bladder every 2 hr. - Correct answer D. Encourage the client to empty her bladder every 2 hr. A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine agony after delivery, increasing the client's risk of postpartum hemorrhage. The lithotomy position is commonly used during delivery. With this position, the client reclines, and her legs are placed in stirrups. This client is only in the first stage of labor, so this would not be an appropriate position at this time. In addition, the client is encouraged to change positions during the labor process because this can relieve fatigue, increase comfort, and improve circulation. Vaginal examination can introduce microorganisms into the vagina that can ascend into the amniotic sac. Frequent vaginal examinations after rupture of membranes increases the risk of infection and should be limited. A client in labor should not be encouraged to push or bear down until the cervix is completely dilated. This client is in the active phase of the first stage of labor. This means that her cervix will be between 0 and 7 cm dilated. It would not be appropriate to have her to push or bear down at this time.