ATI Maternal Newborn quiz 1 & 2 2019 Retake (GRADED A) Questions and Answer elaborations

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1.A nurse is assessing a client who is at 34 weeks gestation and has a mild placental abruption. Which finding should the nurse expect? Dark red vaginal bleeding 2.A nurse is caring for a clien... t who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? Betamethasone(to stimulate fetal lung maturity and prevent respiratory depression) 3.A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which finding should the nurse include in the teaching? Vaginal bleeding 4.A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which finding should the nurse expect? Fetal gastrointestinal anomaly 5.A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which adverse effect should the nurse include in the teaching? Feeling of warmth 6.A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational hypertension. Which finding should the nurse identify as priority? Low urine output (<30mL per hour) 7.A nurse is teaching a client who is at 12 weeks of gestation about the manifestations of potential complications that she should report to her provider. Which information should the nurse include in the teaching? Swelling of the face 8.A nurse is reviewing lab results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type of O negative. Which action should the nurse take? Instruct the client to obtain a rubella immunization after delivery 9.A nurse is caring for a client who has oligohydramnios. Which fetal anomaly should the nurse expect? Renal agenesis 10.A nurse is caring for a client who believes she may be pregnant. Which finding should the nurse identify as a positive sign of pregnancy? Palpable fetal movement 11.A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. What finding should the nurse expect? Uterine contractions 12.A nurse is caring for a client at 26 weeks of gestation and reports constipation. How should the nurse respond? "You should walk for at least 30 min/day" 13.A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which action should the nurse take? Apply pressure to the client's sacral area during contractions 14.A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which finding should the nurse report to the provider? Urinary output 20mL/hour 15.A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. What should the nurse include in the teaching? "You will need to have a full bladder during the ultrasound" 16.A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which assessment provides the most accurate reading of fluid and electrolyte status? Daily weight 17.Which lab test confirms pregnancy (edited question)? A urine test for human chorionic gonadotropin 18.A nurse is caring for a client whose LMP began July 8. What is her EDB? April 15 19.A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24hr. What should the nurse do? Auscultate for a FHR 20.A nurse is assessing a client who is at 12 weeks of gestation and has a hyatidiform mole. What finding should the nurse expect? Dark brown vaginal discharge 21.A nurse is caring for a client in their latent phase of labor and is receiving oxytocin via continuous IV infusion. The client is having contractions every 2 min which last 100 to 110 seconds and the FHR is reassuring. What should the nurse do? Decrease the dose of oxytocin by half 22.A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What information should they include in the teaching? The fibroid can increase the risk for postpartum hemorrhage 23.A nurse is providing teaching to a client who is at 8 weeks of gestation about manifestations to report to the provider during pregnancy. What information should the nurse include in the teaching? Blurred or double vision 24.A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? Obtain blood samples for baseline laboratory values 25.A nurse is teaching a client who is at 12 weeks of gestation and has HIV. What should the nurse include in the teaching? "You should continue to take zidovudine throughout the pregnancy" 26.A nurse is teaching a client who is 13 week of gestation about the treatment of incompetent cervix with cervical cerglage. Which statement by the client indicates an understanding? "I should go to the hospital if I think I may be in labor" 27.A nurse is caring for a client in active labor and has mec stained fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What should the nurse do? Prepare equipment needed for newborn resuscitation 28.A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decals in the FHR. Which finding causes late decels? Uteroplacental insufficiency 29.(Edited question) which order should be questioned with placenta previa? Perform a vaginal exam 30.A nurse is caring for a client at 37 weeks and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What should the nurse do? Use vibroacoustic stimulation on the client's abdomen for 3 seconds 31.A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? use photometer to monitor the lamp's energy 32.A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? place the naked newborn on the mothers bare chest and cover both with a blanket 33.A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? place the newborn directly on the client's chest 34.A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? I will place my baby on his back when it is time for him to sleep 35.A nurse is assessing a newborn 1 min after birth and notes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assigned to the newborn? 9 36.A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? assist the client to empty her bladder 37.A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer? 0.25 38.A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? continue routine monitoring 39.A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? assist the client to ambulate in the hallway 40.A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect? abundant lanugo 41.A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? jaundice of the sclera 42.A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include? boil water for powdered formula for 1-2 min 43.A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? fundal consistency 44.A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the nurse take to promote development? position the naked newborn on the parents bare chest 45.A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? select all prolonged labor mag sulfate infusion distended bladder 46.A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse expect? limited abduction of one hip 47.A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? tonic neck 48.A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse expect? symmetric rib cage 49.A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? this will resolve within 3-6 wks without treatment 50.A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? slow trickle of bright vaginal bleeding and a firm fundus 51.A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification? monitor clients wt wkly 52.A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? place ice packs on your breasts 53.A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1-2 hr of delivery? erythromycin ophthalmic ointment 54.A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh? 1.8 55.A nurse is assisting a client who is 4 hrs postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. What following statements should the nurse make? blood pools in the vagina when you are lying in a bed 56.A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which statement by the client indicates an understanding of the teaching? it is normal for my baby to sometimes feed every hour for several hours in a row 57.A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside? calcium gluconate 58.A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions? Methylergonovine 59.A nurse is administering a rubella immunization to a client who is 2 days postpartum. What statement indicates to the nurse the client needs further instruction? I can conceive anytime i want after 10 days 60.A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. What instructions should the nurse include in the teaching? encourage nonnutritive sucking for pain relief POST-TEST A nurse is teaching the parents of a term newborn how to bathe him. Which of the following instructions should the nurse include? Give him a sponge bath until his cord stump falls off A nurse is assessing a patient who is 1 day postpartum and is not breastfeeding. The nurse notes the patient's breasts are engorged. Which of the following actions is appropriate for the patient to take? Applying ice packs A nurse is assessing a patient at a routine antepartum visit. For a rough estimate of the number of gestational weeks the patient is at, the nurse should measure the number of cm between which two anatomical landmarks? The symphysis pubis and the top of the fundus A nurse is caring for a patient who is in labor and has pain in her lower back because the fetal head is in a posterior position. Which of the following nonpharmacological pain management techniques is likely to be most effective in relieving this type of pain? Counterpressure A nurse is assessing a patient who is at 20 weeks of gestation. She instructs the patient to be sure to report headaches, blurred vision, and swelling of her hands because these are indications of which of the following complications of pregnancy? Preeclampsia A nurse is performing a gestational age assessment using the New Ballard Score for newborn maturity rating. Which of the following findings indicates that the newborn is preterm? Flat areola A newborn delivered vaginally at term 1 min ago cried loudly at delivery, has a heart rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of his feet, and is pink with mild acrocyanosis. What Apgar score should the nurse assigned to this newborn? 8 A patient who is 1 day postpartum tells the nurse that she is concerned about her newborn receiving enough nourishment from breastfeeding. The nurse should explain that she should look for which of the following as a sign of adequate nutrition? The newborn has six wet diapers and three stools per day after day 4. A nurse is performing umbilical cord care for a term newborn. Which of the following findings requires further assessment and intervention Redness at the base A nurse is caring for a term newborn who has just had a circumcision using the Gomco clamp technique. Which of the following instructions should the nurse include when teaching the parents to care for the site? (Select all that apply.) -Apply petroleum jelly to the penis for the first 24 hr -Apply gentle pressure from a sterile gauze pad to control slight bleeding -Apply the diaper loosely over the penis [Show More]

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