VATI RN Maternal Newborn 2019 New Latest Version Updated 2023-2024 with All Questions fro, Exams of Nursing

Download VATI RN Maternal Newborn 2019 New Latest Version Updated 2023-2024 with All Questions fro and more Exams Nursing in PDF only on Docsity! VATI RN Maternal Newborn 2019 New Latest Version Updated 2023-2024 with All Questions from Actual Exam and 100% Correct Answers A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy? -------- Correct Answer -------- Amenorrhea. -A client can present with amenorrhea for a variety of reasons besides pregnancy. 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 is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take? -------- Correct Answer -------- Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement. -To prevent hypotension. A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36wks of gestation. Which of the following actions should the nurse expect to take? -------- Correct Answer -------- Administer IV antibiotic prophylaxis. -To decrease the risk of the neonate contracting a GBS infection, it is recommended that pregnant clients who test positive for GBS receive antibiotics during labor. A nurse is reviewing the results of a nonstress test for a client who is at 37wks of gestation. Which of the following findings indicates a reactive nonstress test? -------- Correct Answer -------- Fetal heart rate (FHR) accelerations occur with fetal movement. -A nonstress test measures the response of the FHR to fetal movement. Accelerations of the FHR with fetal movement are a reassuring sign of fetal well being. A nurse is providing teaching about nifedipine for a client who is at 34wks of gestation and has gestational HTN. For which of the following adverse effects should the nurse instruct the client to notify the provider? -------- Correct Answer -------- Irregular heartbeat. -Cardiac arrhythmia is a potential life-threatening adverse effect of nifedipine. Therefore, the client should report an irregular heartbeat to the provider. A nurse is assessing a client who is in labor, Which of the following findings should the nurse expect? -------- Correct Answer -------- Decrease in blood glucose level. -Maternal metabolism, physical exertion, and delivery of the placenta can lead to a decreased blood glucose level. A nurse is assessing a newborn following a circumcision 48hrs ago. The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following? -------- Correct Answer -------- Healing. -After 24hrs, yellow exudate usually forms over the glans penis and remains for the next 2-3 days. It sometimes forms a crust, which is expected. The nurse should explain that the yellow film the guardians will see is granulation tissue as the circumcision heals. The guardians should not remove this tissue. A nurse is performing an initial assessment during a client's first prenatal visit. The client states that her last menstrual period began April 22. Use Nagele's rule to calculate the expected date of birth (EDB). -------- Correct Answer -------- 0129 -Begin with the first day of the clients last menstrual period, subtract 3 months, and add 7 days. A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia? -------- Correct Answer ------- - Hypotonia -CNS findings of hypoglycemia include lethargy and hypotonia, as well as jitteriness, twitching, poor feeding, temperature instability, apnea, respiratory distress, and seizures. A nurse is teaching a class to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (SATA) -------- Correct Answer -------- 1. Management of postpartum pain -The nurse should discuss with clients that they will have incisional pain associated with uterine involution. 2. Advantage of early ambulation post-surgical procedure. -Early ambulation following a cesarean birth facilitates circulation in the lower extremities, preventing stasis, and assists with relieving gas pains. 3. The need for an indwelling urinary catheter during delivery. -The nurse should place an indwelling urinary catheter prior to the cesarean birth to keep the client's bladder empty and to avoid interference with the surgical procedure. A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the Fetal heart rate. -Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within the expedited reference range and to have a baseline for future assessments. The nurse should provide ongoing assessments of fetal heart rate throughout labor according to facility protocol. 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 monitoring a client who is in the active phase of labor and has an intrauterine pressure catheter and fetal scalp electrode. Which of the following findings should the nurse expect? -------- Correct Answer -------- Montevideo units (MVU) of 220 mm Hg. - The nurse should identify that an MVU of 220 mm Hg is within the expected range during the active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for every contraction that occurs during a 10-min period. The nurse then adds the pressure produced by each contraction during that time to determine the MVUs. A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is 10/min. Which of the following actions should the nurse take first? ----- --- Correct Answer -------- Administer oxygen by nonrebreather face mask. -The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer oxygen by nonrebreather mask to treat manifestations of respiratory depression due to morphine administration. A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect? -------- Correct Answer - ------- Painless vaginal bleeding. -The placenta implants in the lower uterine segment, partially or completely covering the cervix. With cervical changes, the placental blood vessels can tear, which results in bleeding. 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 -------- Episodes of blurred vision. -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. 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 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. 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.