ATI PROCTORED EXAM - MATERNAL NEWBORN, Questions with accurate answers, update 2022/2023

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ATI PROCTORED EXAM - MATERNAL NEWBORN, Questions with accurate answers, update 2022/2023 A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Whic... h of the following actions should the nurse take? - ✔✔D. Use a photometer to monitor the lamp's energy A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? - ✔✔Dark red vaginal bleeding A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? - ✔✔Assess the newborn's blood glucose level A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? - ✔✔C. Calcium gluconate A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? - ✔✔"Place fresh cabbage leaves on your breasts." A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? - ✔✔"You should eat dry foods that are high in carbohydrates when you wake up." A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? - ✔✔"A progestin-only pill or injection is available for use while you are breastfeeding." A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? - ✔✔Urine output 20 mL/hr A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? - ✔✔B."You will receive a medication to relax your uterus prior to the procedure. A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? - ✔✔"This is a source of your fluid loss after delivery." The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? - ✔✔Autosomal recessive A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? - ✔✔C. Stress incontinence A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? - ✔✔B.Sponge bathe the newborn every other day A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? - ✔✔Apply cold ice packs to the client's perineaium A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? - ✔✔"I will place my baby on his back when putting him to sleep." A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? - ✔✔Abundant lanugo A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? - ✔✔Assess the newborn for respiratory depression A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? - ✔✔Urinary retention A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? - ✔✔Fetal gastrointestinal anomaly A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? - ✔✔"You should slightly increase your exposure to sunlight." A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? - ✔✔Pelvic inflammatory disease (PID) A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? Show Explanation - ✔✔Dark brown vaginal discharge A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? Show Explanation - ✔✔Frequent headaches A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? - ✔✔Renal agenesis A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? Show Explanation - ✔✔Ask the client when she last voided A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? Show Explanation - ✔✔Maternal hypotension A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? Show Explanation - ✔✔Daily weight A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? Show Explanation - ✔✔Massage the fundus A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? Show Explanation - ✔✔Provide a sitz bath with warm water for the client A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? - ✔✔Correct Answer: D. Slow-paced breathing Slow-paced breathing is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation. Incorrect Answers: A. Self-hypnosis can help relieve labor pain, but clients might not be able to perform it if they haven't already learned from specially trained practitioners. B. Biofeedback can help relieve labor pain, but clients might not be able to implement it if they haven't already learned from specially trained practitioners. C. Specially trained practitioners perform acupuncture, so this is not something the nurse can initiate. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside? - ✔✔Correct Answer: Calcium gluconate The nurse should have calcium gluconate available for a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate of ≤12/min, muscle weakness, and depressed deep-tendon reflexes. Incorrect Answers: A. The nurse should have naloxone available for a client who is receiving opioid medication in case of respiratory depression. C. The nurse should have protamine sulfate available for a client who is receiving heparin in case of hemorrhage. D. The nurse should have atropine available for a client who is receiving medications that can lead to asystole or sinus bradycardia, such as beta-adrenergic blockers. A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? - ✔✔Correct Answer: Fetal asphyxia Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia. Incorrect Answers: A. Diarrhea is not an adverse effect of oxytocin administration. Oxytocin can have adverse effects that include fetal asphyxia, water intoxication, hypotension, and abruptio placentae. B. Thromboembolism is not an adverse effect of oxytocin administration. D. Oliguria is not a likely complication of oxytocin administration. A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate? Show Explanation - ✔✔Correct Answer: Calcium gluconate Calcium gluconate should be kept available as the antidote for magnesium sulfate toxicity. Incorrect Answers: A. Betamethasone is administered to help mature the lungs of the premature fetus before delivery. It is not an antidote to magnesium sulfate. B. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in premature labor. It is not an antidote to magnesium sulfate. D. Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor. It is not an antidote to magnesium sulfate. A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? Show Explanation - ✔✔Correct Answer: "I may notice increased cramping when I am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction. Incorrect Answers: A. A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well established (in approximately 3 or 4 weeks). D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive. A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? Show Explanation - ✔✔orrect Answer: Copper intrauterine device A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper intrauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier methods and spermicides. Incorrect Answers: B. A history of thrombophlebitis is a contraindication for taking oral contraceptives. Safer methods of contraception for this client include barrier methods and spermicides. C. A history of thrombophlebitis is a contraindication for a vaginal insert that releases hormones continuously. Safer methods of contraception for this client include barrier methods and spermicides. D. A history of thrombophlebitis is a contraindication for injectable progestins. Safer methods of contraception for this client include barrier methods and spermicides. A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? Show Explanation - ✔✔Correct Answer: "I should press the button on the handheld marker when my baby moves." The purpose of the test is to assess fetal wellbeing. The client should press the button on the handheld marker when she feels fetal movement. Incorrect Answers: A. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers the client orange juice to stimulate the fetus. B. The client does not need medication to induce contractions. Oxytocin is used to induce contractions for an oxytocin challenge test. D. The client does not need to perform nipple stimulation to induce contractions; this is needed for a contraction stress test. A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? - ✔✔Correct Answer: B. "If the test is positive, that means your baby's heart rate is healthy." The fetal heart rate is considered healthy if the results of nonstress testing are positive. If the test is negative, fetal health may be affected, and further testing may be necessary to rule out poor oxygen perfusion of the fetus. Incorrect Answers:A. Nonstress testing is noninvasive and causes no risk to either the client or the fetus. It can be used as a screening procedure in all pregnancies. C. The test measures the response of the fetal heart rate to fetal movement. The fetal heart rate should increase by about 15 beats/min when the fetus moves and should remain increased for about 15 seconds. D. The test would be identified as nonreactive if there is no fetal movement during the testing period or if the fetal heart rate variability is under 6 beats/min. A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? - ✔✔Correct Answer: A. Accepting the pregnancy Accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester. Incorrect Answers:B. Preparing for the end of pregnancy is a psychological task that the client is expected to accomplish during the third trimester. C. Preparing for parenthood is a psychological task that the client is expected to accomplish during the third trimester. D. Accepting the baby is a psychological task that the client is expected to accomplish during the second trimester. A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? - ✔✔Correct Answer: A. Painless, bright red bleeding Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include bright red vaginal bleeding and a fundal height higher than expected for the gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus. Incorrect Answers:B. Uterine hypertonicity is a manifestation of placental abruption, not placenta previa. C. Uterine tonicity is normal with placenta previa; it does not cause contractions. D. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa. A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? Show Explanation - ✔✔Correct Answer: C. October 27 Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and adding 7 days. Incorrect Answers:A. An expected date of delivery of October 13 would follow a last menstrual period date of January 6. B. An expected date of delivery of November 13 would follow a last menstrual period date of February 6. D. An expected date of delivery of November 27 would follow a last menstrual period date of February 20. A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? Show Explanation - ✔✔Correct Answer: D. Gonorrhea Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC. Incorrect Answers:A. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection. Manifestations include client report of a "fishy odor" and vaginal discharge that appears thin, watery, gray, white, or milky. The client might also report pruritus. This vaginal infection does not require reporting; however, it should be treated with metronidazole or clindamycin cream. B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting. C. Candidiasis, also known as a yeast infection, is the second-most common vaginal infection. Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching. This vaginal infection does not require reporting. A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? - ✔✔Correct Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested. Incorrect Answers:A. This is a close-ended response that discourages further communication. C. This is a close-ended response that discourages further communication and is both nontherapeutic and inaccurate. D. Asking "why" questions typically makes clients feel defensive. A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? Show Explanation - ✔✔Correct Answer: B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations. Incorrect Answers:A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIV-positive. C. The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? - ✔✔Correct Answer: B. Double vision Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. Incorrect Answers:A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the relaxation of the smooth muscle walls of the veins and pelvic vasocongestion. C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common manifestation associated with pregnancy. D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced gastrointestinal motility. A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? - ✔✔Correct Answer: C. Palpating the client's fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery follows a labor of <3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage. Incorrect Answers:A. The nurse should monitor the client's temperature during the fourth stage of labor; however, another assessment is the priority. B. The nurse should assess the client's perineum, especially if an episiotomy or laceration is present; however, another assessment is the priority. D. The nurse should check the client for hemorrhoids during the fourth stage of labor; however, another assessment is the priority. A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? Show Explanation - ✔✔Correct Answer: C. Give oxygen at 10 L/min via face mask The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to help stabilize the client's respiratory status. Incorrect Answers:A. The nurse should administer magnesium sulfate to prevent further seizure activity; however, there is another action the nurse should take first. B. The nurse should insert an indwelling urinary catheter to monitor the client's fluid output. Fluids should be restricted for a client who has eclampsia, but the client's output should be at least 25 mL/hr. However, there is another action the nurse should take first. D. The nurse should reduce environmental stimuli to help prevent further seizure activity and to promote rest following the seizure; however, there is another action the nurse should take first. A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? - ✔✔Correct Answer: D. The fetal heart rate is 90/min. Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority finding. Incorrect Answers:A. The nurse should intervene to help ease the client's pain; however, another assessment finding is the priority. B. The nurse should recheck the client's blood pressure in 30 minutes after the client has relaxed and between contractions to help rule out preeclampsia; however, another assessment finding is the priority. C. The nurse should notify the provider and perform a thorough assessment to rule out an infection such as chorioamnionitis; however, another assessment finding is the priority. A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? - ✔✔Correct Answer: B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed. Incorrect Answers:A. The nurse should administer the HBV vaccine prior to discharge. There is no indication to administer the vaccine within 1 hour after birth. C. The nurse should not bathe the newborn until the newborn's temperature has stabilized in the extra-uterine environment. Ideally, the nurse should place the infant in skin-to-skin contact with the mother for at least the first 1 to 2 hours after birth. Alternately, the nurse can place the newborn under a radiant heat source and assess the newborn's temperature every hour until it is stabilized. D. The nurse should use a pulse oximeter to screen for congenital heart disease 24 to 48 hours after birth. If the nurse performs the screening prior to 12 hours after birth, acrocyanosis might alter the results. A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? - ✔✔Correct Answer: D. "You should continue to take zidovudine throughout the pregnancy." The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmitting HIV to her newborn. Incorrect Answers:A. The client can transmit HIV through breast milk and should bottle-feed her newborn. B. The client can continue to have sexual intercourse during pregnancy, as long as a condom is used. C. The client and her newborn will only require standard precautions after delivery. A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? - ✔✔Correct Answer: D. Dry the newborn The greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemia. Therefore, the first action the nurse should take is to dry the newborn to prevent heat loss from evaporation. Incorrect Answers:A. The nurse should obtain the newborn's weight within 1 to 2 hours after birth. However, there is another action the nurse should take first. B. The nurse should instill erythromycin ophthalmic ointment in the newborn's eyes after the first breastfeeding to prevent infection. However, there is another action the nurse should take first. C. The nurse should administer vitamin K to the newborn within 1 to 2 hours after birth to prevent bleeding. However, there is another action the nurse should take first. A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? - ✔✔Correct Answer: [Show More]

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