ATI Maternal Newborn Proctored Exam

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ATI Maternal Newborn Proctored Exam 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Incorrect: Lochia does change color bu... t goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. Incorrect: Numerous clots are abnormal and should be reported to the physician. Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. The color of the lochia changes from a bright red to white after four days Numerous large clots are normal for the next three to four days Saturation of the perineal pad with blood is expected when getting up from the bed Lochia should last for about 3 weeks, changing color every few days 2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. Incorrect: Variable decelerations (not late decelerations) are associated with cord compression. Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. Correct: Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress. The umbilical cord is wrapped tightly around the fetus' neck The fetal cord is being compressed due to rapid descent of the fetal head Maternal contractions are not adequate enough to deliver the fetus The fetus is not receiving adequate oxygen and is in distress 2 A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source 3 an assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess? Head injury HR 60 5 A community health nurse recognizes that the teen pregnancy rate in the community has increased. Which of the following program-planning strategies should the nurse implement first? Arrange a meeting with teenage mothers who are high school students in the community 6 After making morning rounds, the charge nurse on a surgical unit delegates the following task to the assistive personnel, which of the following task does the nurse direct the AP to complete first? Place an NPO sign on the door of a client scheduled surgery A nurse is educating a client on how to perform Kegel exercise therapy for urinary incontinence. Which of the following points should be included in teaching? Select all that apply. Select one or more: a. While sitting on the toilet, strain down to help identify pelvic muscles. b. Have a designated time and place for completing therapy. c. Complete exercises in only a sitting position. d. Improvement in incontinence may be seen after 6 weeks of exercise therapy. e. During exercises, tighten pelvic muscles for a count of 10 and then relax for a count of 10. b. Have a designated time and place for completing therapy. d. Improvement in incontinence may be seen after 6 weeks of exercise therapy. e. During exercises, tighten pelvic muscles for a count of 10 and then relax for a count of 10. At first, it is helpful to have a designated time and place to do exercises because the client will need to concentrate to do them correctly. Although improvement may take several months, most clients notice a positive change after 6 weeks of exercises. The client should be educated to tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10. This exercise should be done 15 times while lying down, sitting up, and standing (a total of 45 exercises). The client should then repeat the exercises rapidly contracting and relaxing the pelvic muscles 10 times. This should take no longer than 10 to 12 minutes for all three positions, or 3 to 4 minutes for each set of 15 exercises. 1) A nurse is preforming a newborn assessment. Which of the following images should the nurse Identify as an indication of spina bifida occulta? tuff of hair 2) A nurse is assessing a client who is 12 hr postpartum. The client's fundus is two fingerbreadths above the umbillicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take? assist the client to the bathroom to void 3) A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? You will be offered orange juice to drink during the test [Show More]

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