ATI. MATERNAL-NEWBORN proctored exam

ATI. MATERNAL-NEWBORN

1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?

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?

3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?

4. Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?

5. A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering?

6. Which of the following are probable signs, strongly indicating pregnancy?

7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?

8. Which site is preferred for giving an IM injection to a newborn?

9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?

10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive?

11. Which assessment finding indicates that placental separation has occurred during the third stage of labor?

12. The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are:

13. During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of “pain related to perineal sutures.” Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?

14. A client asks the nurse about the benefits of breastfeeding. Which response by the nurse provides the most accurate information?

15. Which physiological change takes place during the puerperium?

16. A client delivered two days ago and is suspected of having postpartum "blues." Which symptoms confirm the diagnosis?

17. Shortly after delivery, the nursery nurse gives the newborn an injection of phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got “a shot in his leg.” Which response by the nurse is most appropriate?

18. At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct?

19. A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?

20. An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?

21. A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant? It will cause the infant's:

22. For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?

23. A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?

24. In which position should the nurse place the laboring client in order to increase the intensity of the contractions and improve oxygenation to the fetus?

Incorrect: This position is contraindicated because the fetus creates pressure on the mother's vena cava. Incorrect: Squatting widens the pelvic inlet, but does not improve contractions or fetal oxygenation.

25. A woman enters the birthing center in active labor. She tells the nurse that her membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs. Which is the rationale for the nurse's actions?

26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a4-year-old and a set of 1-year-old twins. How should the nurse record the client's current gravida and para status?

27. A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important?

28. A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?

30. The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:

31. With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy?

32. A breastfeeding mother complains of cramping. Which is the main cause of the client's afterpains?

33. A client who is 37 weeks gestation comes to the office for a routine visit. This is the client's first baby and she asks the nurse how she will know when labor begins. Which signs indicate that true labor has begun?

34. A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care afterbirth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:

35. The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?

36. For a pregnant adolescent who is anemic, which foods should the nurse include In the client's dietary plan to increase iron levels?

37. Which condition must occur in order for identical (monozygotic) twins to develop?

38. Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus?

39. A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor in the client's history supports this diagnosis? The client states that she:

40. Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn?

41. A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery?

42. Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?

43. The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?

44. Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?

45. A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client?

70. A new mother receives instructions about care of her newborn son's circumcision. Which statement made by the mother indicates that further teaching is needed?

71. A 17-year-old client delivered her first baby 8 hours ago. Which of the following is an indication that appropriate bonding is occurring? The client:

72. A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond?

73. During the active phase of labor, the membranes rupture and the nurse notes green amniotic fluid. Which nursing action should be initiated immediately?

74. At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician?

75. A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is: