Download VATI RN Maternal Newborn 2019 questions with 100% verified answers updated 2023 and more Exams Nursing in PDF only on Docsity! VATI RN Maternal Newborn 2019 A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - ANS Encourage client who are prescribed methadone to breastfeed. -The nurse should encourage clients who are prescribed methadone during pregnancy to breastfeed their newborns to help with withdrawal symptoms. A nurse is caring for a client who received terbutaline subcutaneously. Which of the following findings is an indication the medication was effective? - ANS Decreased frequency of contractions. -Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse should identify that a decrease in frequency of contractions is an indication that terbutaline was effective. A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching regarding situations requiring an amniotomy? - ANS Placing a fetal scalp electrode. VATI RN Maternal Newborn 2019 -A fetal scalp electrode is attached to the presenting part of the fetus in order to provide accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access to the presenting part. A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication? - ANS Heart rate 54/min -The nurse should identify that a heart rate of 54/min is below the expected reference range of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood volume and increase tissue demands for oxygen. Bradycardia is a contraindication for the administration of labetalol, an antihypertensive medication. Therefore, the nurse should withhold the medication and notify the provider. A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the nurse should take to clear the airway obstruction. - ANS 1. Stand posterior to the client. 2. Position arms under the client's axilla and across the client's chest. 3. Place thumb-side of a clenched fist to the client's mid-sternum area. 4. Initiate chest thrust to the client using a backward motion. VATI RN Maternal Newborn 2019 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? - ANS 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? - ANS 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? - ANS 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. VATI RN Maternal Newborn 2019 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) - ANS 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? - ANS 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? - ANS Firmly massage the fundus. VATI RN Maternal Newborn 2019 -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? - ANS 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? - ANS 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 VATI RN Maternal Newborn 2019 instructions should the nurse include in the teaching? - ANS 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? - ANS 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? - ANS 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 VATI RN Maternal Newborn 2019 following actions should the nurse take? - ANS 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? - ANS 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. - ANS 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. VATI RN Maternal Newborn 2019 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? - ANS 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 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? - ANS Amenorrhea. -A client can present with amenorrhea for a variety of reasons besides pregnancy. 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? - ANS 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? - ANS Administer IV antibiotic prophylaxis. VATI RN Maternal Newborn 2019 -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 nurse include in the teaching? - ANS Bring your newborn in the bassinet into the bathroom with you. -The client should wheel the newborn in the bassinet into the bathroom with her rather than leave the newborn unattended. The nurse should instruct the client never to leave the newborn unattended. A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make? - ANS The most accurate indication of organ perfusion is a clients urine output. VATI RN Maternal Newborn 2019 -Output greater than 30 mL/hr. is an indication of adequate perfusion and oxygenation. A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48hrs after birth. Which of the following findings should the nurse report to the provider? - ANS Depressed fontanels. -Sunken or depressed fontanels are a finding associated with dehydration of the newborn. Additionally, dry oral mucosa, weight loss greater than 10%, and decreased urine output are findings associated with dehydration. 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? - ANS 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? - ANS 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. VATI RN Maternal Newborn 2019 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? - ANS 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? - ANS 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? - ANS 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. VATI RN Maternal Newborn 2019 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? - ANS 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? - ANS 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? - ANS 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? - ANS Monitor intake and output. VATI RN Maternal Newborn 2019 -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? - ANS 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? - ANS 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? - ANS 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 VATI RN Maternal Newborn 2019 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? - ANS 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? - ANS 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? - ANS 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. VATI RN Maternal Newborn 2019 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? - ANS 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? - ANS 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? - ANS 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. A nurse is assessing a newborn who was born 15min ago and has an axillary temperature of 36.1C (97F). Which of the following actions should the nurse take? - ANS Place the newborn skin to skin on the mother's chest. VATI RN Maternal Newborn 2019 -Expected reference range is 36.5-37.5C (97.7-99.5F) for a newborn. This temperature indicates hypothermia. Hypothermia can lead to cold stress, causing tachypnea, decreased pulmonary perfusion, and hypoglycemia. A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due to a postpartum hemorrhage. Which of the following findings is the best indication of adequate perfusion and oxygenation? - ANS Urinary output. -Greatest risk for the client is coma and cardiac arrest if adequate perfusion and oxygenation are not achieved. The nurse should identify that a urinary output of at least 30 mL/hr. is the best indication of adequate perfusion and oxygenation. The nurse should insert an indwelling urinary catheter in a client who is experiencing manifestations of hypovolemic shock. A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse report to the provider? - ANS Hct 31% -Below the minimal expected value of greater than 33% during pregnancy. The nurse should report this finding to the provider as it is an indication of anemia. A nurse is monitoring the laboratory results for a client who has preeclampsia with severe features. Which of the following results should the nurse expect? - ANS Increased BUN. VATI RN Maternal Newborn 2019 -Preeclampsia with severe features to exhibit an increase in BUN, or blood urea nitrogen. The increase is caused by a decreased glomerular filtration rate, secondary to impaired renal perfusion. A nurse is preparing to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take? - ANS Warm the newborn's heel for 10mins prior to the puncture. -Warm heel for 5-10mins prior to puncture. Warming the heel causes vasodilation which enhances blood flow to the puncture site. A nurse is reviewing the laboratory report of a client who is at 31wks of gestation and has gestation hypertension. Which of the following laboratory results should the nurse report to the provider? - ANS Platelet count 99,000/mm3. -A platelet count of 99,000/mm3, or thrombocytopenia, is an indication of HELLP syndrome, a serious complication of gestational HTN. A nurse is reviewing the laboratory report of a term newborn who is 24hrs old. Which of the following laboratory results should the nurse report to the provider? - ANS Glucose 35 mg/dL. -Reference range is 40-45 mg/dL for a newborn who is 24hrs old.