Maternal-Newborn ATI Overview

Maternal newborn ati proctored exam A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan? Remove all clothing form the newborn except the diaper A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Monitor the FHR A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? Reports of decreased fetal movement A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority? Begin FHR monitoring A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test? Biophysicial profile A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? 50 ml/hr A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? BUN 25 mg/dL A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Respiratory distress A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the development of preeclampsia Pregestational Diabetes Mellitus A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? Fundal Height Measurement A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? Substernal Retractions A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure? Administer oxygen via a nonrebreather mask A nurse is providing teaching about nonpharmological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? Cold cabbage leaves A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? Vaginal pressure A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil A nurse is providing teaching for a client who have birth 2 hr ago the person who comes to take my baby's pictures will be wearing about the facility policy for newborn safety. Which of the following a photo identification badge client statements indicates an understanding of the teaching? A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? Report of visual disturbances 1 / 16 A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? "I will likely need to use alternative positions for sexual intercourse". A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the following outcomes should the nurse expect? A reduction in respiratory distress in the newborn A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? Calcium Gluconate A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Respiratory rate 10/min A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider? Late Decelerations A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include? "You should press the handheld button when you feel your baby move." A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? Petechiae over the head A nurse is transporting a newborn back to the parent's room Verify that the parent's identification band matches the newborn's following a procedure. Which of the following actions should the identification band nurse take? A nurse is creating a plan of care who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? Protects the client's head and feet from cold air A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopoid maneuvers. Which of the following images indicates the first step of Leopoid maneuvers? Picture of nurse palpating top of belly; where bottom is A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the FHR continously A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Weight gain of 2.2 kg (4.8 lb) A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? To locate the pocket of fluid 2 / 16 A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness Answer: Shortness of breath A. Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of A nurse is teaching a client who has a new prescription for comother adverse effects that can indicate potential complications, inbined oral contraceptives about potential adverse effects of the cluding abdominal pain, sudden or persistent headaches, blurred medication. For which of the following findings should the nurse vision, and severe leg pain. instruct the client to notify the provider? B. Breakthrough bleeding Breakthrough bleeding outside the menstrual period is a common adverse effect of combined oral contraceptives. C. Vomiting Nausea and vomiting are common adverse effects of combined oral contraceptives. D. Breast tenderness Breast tenderness is a common adverse effect of combined oral contraceptives. A. Increased fetal movement B. Leakage of fluid from the vagina C. Upper abdominal discomfort D. Urinary frequency Answer: Leakage of fluid from the vagina A. Increased fetal movement Decreased fetal movement is a potential complication that should be reported to the provider. A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? B. Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. C. Upper abdominal discomfort Upper abdominal discomfort is not a potential complication associated with an amniocentesis. D. Urinary frequency Urinary frequency is not a potential complication associated with an amniocentesis. Answer: September 3rd A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? A. September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd. 3 / 16 A. Percutaneous umbilical blood sampling B. Amnioinfusion C. Biophysical profile (BPP) D. Chorionic villus sampling (CVS) Answer: Biophysical profile (BPP) A. Percutaneous umbilical blood sampling Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for A nurse is caring for a client who is at 41 weeks of gestation and clients who have a positive contraction stress test. has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? B. Amnioinfusion An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic uid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test. C. Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction st A. "You can share your room with your baby for the next few weeks." B. "Cover your baby with a light blanket while sleeping." C. "Check the temperature of your baby's bath water with your hand." D. "Your baby can nap in the car seat during the daytime." Answer: "You can share your room with your baby for the next few weeks." A. "You can share your room with your baby for the next few weeks." A nurse is teaching a new parent about newborn safety. Which of The nurse should recommend room-sharing during the first few the following instructions should the nurse include in the teaching? weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. B. "Cover your baby with a light blanket while sleeping." The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for sudden infant death syndrome. C. "Check the temperature of your baby' A. Apply sacral counterpressure. B. Perform transcutaneous electrical nerve stimulation (TENS). C. Initiate slow-paced breathing. D. Assist with biofeedback. A nurse is caring for a client who is in labor and whose fetus is in Answer: Apply sacral counterpressure. the right occiput posterior position. The client is dilated to 8 cm A. Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. B. Perform transcutaneous electrical nerve stimulation (TENS). 4 / 16 The nurse should perform TENS during the first stage of labor. and reports back pain. Which of the following actions should the nurse take? C. Initiate slow-paced breathing. The nurse should transition a client to pattern-paced breathing during this stage of labor. D. Assist with biofeedback. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor. A. Cover the newborn's eyes while under the phototherapy light. B. Keep the newborn in a shirt while under the phototherapy light. C. Apply a light moisturizing lotion to the newborn's skin. D. Turn and reposition the newborn every 4 hr while undergoing phototherapy. Answer: Cover the newborn's eyes while under the phototherapy light. A. Cover the newborn's eyes while under the phototherapy light. A nurse is caring for a newborn who is undergoing phototherapy Applying an opaque eye mask prevents damage to the newborn's to treat hyperbilirubinemia. Which of the following actions should retinas and corneas from the phototherapy light. the nurse take? B. Keep the newborn in a shirt while under the phototherapy light. It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light. C. Apply a light moisturizing lotion to the newborn's skin. The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns. A. Place a rolled towel beneath one of the client's hips. B. Apply internal upward pressure to the presenting part using two gloved fingers. C. Administer oxygen to the client via a nonrebreather mask at 10 L/min. D. Increase the IV infusion rate. Answer: Apply internal upward pressure to the presenting part using two gloved fingers. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. A. Place a rolled towel beneath one of the client's hips. After calling for assistance, which of the following actions should The nurse should place a rolled towel under the client's left or right the nurse take next? hip to alleviate some of the pressure; however, evidence-based practice indicates that the nurse should take a different action first. B. Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compr 5 / 16 A. Flaccid uterus B. Cervical laceration C. Excess vaginal bleeding D. Increased afterbirth cramping E. Increased maternal temperature Answer: Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Cervical laceration is incorrect. Bleeding resulting from a cervical A nurse is preparing to administer oxytocin to a client who is laceration continues even when the uterus is contracted and firm. postpartum. Which of the following findings is an indication for the It will require repair by the provider. administration of the medication? (SATA) Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature. A. "The nurse will carry your newborn to the nursery for procedures." B. "We will document the relationship of visitors in your medical record." C. "Your baby will stay in the nursery while you are asleep." D. "Staff members who take care of your baby will be wearing a photo identification badge." Answer: "Staff members who take care of your baby will be wearing a photo identification badge." A nurse is teaching a postpartum client about steps the nurses will A. "The nurse will carry your newborn to the nursery for procetake to promote the security and safety of the client's newborn. dures." Which of the following statements should the nurse make? The nurse should instruct the client that newborns will be transported in their bassinets and never carried outside the client's room to reduce the risk for falls. B. "We will document the relationship of visitors in your medical record." The nurse should instruct the client that they can have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record. C. "Your baby will stay in the nursery while you are asleep." The nurse should instruct the client to p A. Large for gestational age B. Hyperglycemia C. Bradypnea D. Vomiting Answer: Vomiting A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the A. Large for gestational age Low birth weight is an expected manifestation of fetal exposure to SSRIs. B. Hyperglycemia Hypoglycemia is an expected manifestation of fetal exposure to 6 / 16 SSRIs. C. Bradypnea Tachypnea is an expected manifestation of fetal exposure to SSRIs. following manifestations should the nurse identify as an indication of withdrawal from an SSRI? D. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Answer: Vomiting A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant Answer: Left lower quadrant A. Left upper quadrant The fetal heart tones of a fetus in the left sacrum anterior position A nurse is assessing fetal heart tones for a client who is pregnant. are best heard in the left upper quadrant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should B. Right upper quadrant the nurse apply the ultrasound transducer to assess the point of The fetal heart tones of a fetus in the right sacrum anterior position maximum intensity of the fetal heart? are best heard in the right upper quadrant. C. Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. D. Right lower quadrant The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant. A. Insert the syringe tip before compressing the bulb. B. Suction each of the nares before suctioning the mouth. C. Insert the tip of the syringe into the center of the newborn's mouth. D. Stop suctioning when the newborn's cry sounds clear. Answer: Stop suctioning when the newborn's cry sounds clear. A. Insert the syringe tip before compressing the bulb. The client should compress the bulb before inserting the syringe A nurse is teaching a new mother how to use a bulb syringe to tip. Compressing the bulb after it is in the newborn's nares or suction her newborn's secretions. Which of the following instruc- mouth could push the secretions and mucus further inside. tions should the nurse include? B. Suction each of the nares before suctioning the mouth. The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. C. Insert the tip of the syringe into the center of the newborn's mouth. The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigge 7 / 16 A. Hct 39% B. Serum albumin 4.5 g/dL C. WBC 9,000/mm3 D. Platelets 50,000/mm3 Answer: Platelets 50,000/mm3 A. Hct 39% An Hct of 39% is within the expected reference range and does not indicate a postpartum complication. A nurse is reviewing the medical record of a client who is postB. Serum albumin 4.5 g/dL partum and has preeclampsia. Which of the following laboratory A serum albumin level of 4.5 g/dL is within the expected reference results should the nurse report to the provider? range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. C. WBC 9,000/mm3 A WBC of 9,000/mm3 is within the expected reference range and does not indicate a postpartum complication. D. Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. A. The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area. B. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is closed. External indications of this neural tube defect include a herniated sac over the site of the defect that is covered with skin. A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta? C. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is open. External indications of this neural tube defect include an open area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms. D. The nurse should identify this as an image of Mongolian spots. These bluish-black pigmented areas are most commonly found on the buttocks and back of newborns of Mediterranean, Asian, African, and Latin American ethnicity and can be incorrect A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL B. A client who is at 34 weeks of gestation and reports epigastric pain C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria Answer: A client who is at 34 weeks of gestation and reports epigastric pain A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes, which is a nonurgent finding. Therefore, another client is the nurse's priority. 8 / 16 B. A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. There A. "I will eat foods that taste good instead of balancing my meals." B. "I will avoid having a snack before I go to bed each night." C. "I will have a cup of hot tea with each meal." D. "I will eliminate products that contain dairy from my diet." Answer: "I will eat foods that taste good instead of balancing my meals." A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicated an understanding of the teaching? A. "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. B. "I will avoid having a snack before I go to bed each night." Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. C. "I will have a cup of hot tea with each meal." Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. D. "I will eliminate produc A. Discuss contraceptive options with the client and her partner. B. Repeat information to ensure client understanding. C. Listen to the client and her partner as they reflect upon the birth experience. D. Demonstrate to the client how to perform a newborn bath. Answer: Demonstrate to the client how to perform a newborn bath. A. Discuss contraceptive options with the client and her partner. A nurse is planning care for a client who is 2 hr postpartum. The discussing of contraceptive options occurs during the letWhich of the following interventions should the nurse plan to ting-go phase. This phase focuses on moving forward as a family implement during the taking-hold phase of postpartum behavioral with interchanging members. adjustment? B. Repeat information to ensure client understanding. The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said 9 / 16 A. Swelling of the face B. Varicose veins in the calves C. Nonpitting 1+ ankle edema D. Hyperpigmentation of the cheeks Answer: Swelling of the face A. Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? B. Varicose veins in the calves Varicose veins are an expected finding in the second trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities. C. Nonpitting 1+ ankle edema Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight c A. Jitteriness B. Hypertonia C. Abdominal distention D. Mottling Answer: Jitteriness A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A. Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. B. Hypertonia Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a manifestation of opioid withdrawal. C. Abdominal distention Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a finding in newborns who have hypocalcemia. D. Mottling Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in newborns. Also, it is a manifestation of opioid withdrawal. A. "I will get injections of the medication once daily until my labor stops." B. "My blood sugar may be low while I'm on this medication." C. "I will have blood tests because my potassium might decrease." D. "My blood pressure may increase while I'm on this medication." Answer: "I will have blood tests because my potassium might decrease." A. "I will get injections of the medication once daily until my labor 10 / 16 stops." Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. B. "My blood sugar may be low while I'm on this medication." A nurse is teaching a client who is in preterm labor about terbuAn adverse effect of terbutaline is hyperglycemia. taline. Which of the following statements by the client indicates an understanding of the teaching? C. "I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia. D. "My blood pressure may increase while I'm on this medication." An adverse effect of terbutaline is hypotension. A. O2 saturation B. Temperature C. Blood pressure D. Urinary output Answer: Temperature A. O2 saturation Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. A nurse is planning care for a client who is in labor and is having an amniotomy. Which of the following assessments should the nurse B. Temperature identify as the priority? The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. C. Blood pressure Assessing the client's blood pressure is important. However, another assessment is the nurse's priority. D. Urinary output Assessing the client's urinary output is important during labor. However, another assessment is the nurse's priority. A. Place warm, moist packs on the breasts. B. Apply cabbage leaves to the breasts. C. Wear a loose-fitting bra. D. Put green tea bags on the breasts. Answer: Apply cabbage leaves to the breasts. A. Place warm, moist packs on the breasts. The client can use cold compresses to decrease breast discomfort during lactation suppression. A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions B. Apply cabbage leaves to the breasts. should the nurse include in the plan of care for lactation suppres- Plant sterols and salicylates from cabbage leaves can help to sion? relieve swelling and discomfort caused by breast engorgement. C. Wear a loose-fitting bra. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. D. Put green tea bags on the breasts. Tea bags are used to relieve nipple soreness in breastfeeding clients. Answer: Apply cabbage leaves to the breasts. 11 / 16 A. Determine respiratory function. B. Increase the IV fluid rate. C. Access emergency medications from cart. D. Collect a maternal blood sample for coagulopathy studies. Answer: Determine respiratory function. A. Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the B. Increase the IV fluid rate. nurse take first? The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. C. Access emergency medications from cart. The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. D.Collect a maternal blood sample for coagulopathy studies. The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should tak A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." C. "I will continue taking my insulin if I experience nausea and vomiting." D. "I will ensure that my bedtime snack is high in refined sugar." Answer: "I will continue taking my insulin if I experience nausea and vomiting." A nurse is teaching a client who has pregestational type 1 diaA. "I should have a goal of maintaining my fasting blood glucose betes mellitus about management during pregnancy. Which of the between 100 and 120." following statements by the client indicates an understanding of The nurse should teach the client to maintain her fasting blood the teaching? glucose level between 60 and 99 mg/dL. B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. C. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to A. Decreased heart rate B. Chin quivering C. Pinpoint pupils D. Slowed respirations A nurse is assessing a newborn following a circumcision. Which Answer: Chin quivering of the following findings should the nurse identify as an indication that the newborn is experiencing pain? A. Decreased heart rate The heart rate will increase when a newborn is experiencing pain. B. Chin quivering Behavioral responses to a newborn's pain include facial expres12 / 16 sions such as chin quivering, grimacing, and furrowing of the brow. C. Pinpoint pupils When experiencing pain, a newborn's pupils typically dilate. D. Slowed respirations When experiencing pain, a newborn's respirations are typically rapid and shallow. A. Emotional lability B. Focusing phase C. Cognitive restructuring D. Couvade syndrome Answer: Emotional lability A. Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that A nurse in the antepartum clinic is assessing a client's adaptation occur during pregnancy. Tears and anger alternate with feelings to pregnancy. The client states that she is, "happy one minute of joy or cheerfulness for little or no reason. and crying the next." The nurse should interperate the client's statement as an indication of which of the following? B. Focusing phase The focusing phase is the third phase of the father's emotional response to the pregnancy. It is characterized by his active involvement in the pregnancy and his relationship with the child. C. Cognitive restructuring Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the woman's life. The degree of acceptance is shown in the mother's emotional responses. D. Couvade syndrome Couvade syndrome is pregnancy-like manifestations experienced by t Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in Human papillomavirus is incorrect. the client's hx should the nurse recognize as a contraindication to The presence of human papillomavirus is not a contraindication oral contraceptives? (SATA) for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives. 13 / 16 A. "You should take the medication within 72 hours following unprotected sexual intercourse." B. "You should avoid taking this medication if you are on an oral contraceptive." C. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." D. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it." Answer: "You should take the medication within 72 hours following A school nurse is providing teaching to an adolescent about unprotected sexual intercourse." levonorgestrel contraception. Which of the following information should the nurse include in the teaching? A. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. B. "You should avoid taking this medication if you are on an oral contraceptive." Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent m A. Place the shoulder harness in the slots above the newborn's shoulders. B. Place the retainer clip at the level of the newborn's armpits. C. Place the newborn at a 60° angle in the car seat. D. Place the newborn in a blanket before securing them in the car seat. Answer: Place the retainer clip at the level of the newborn's armpits. A. Place the shoulder harness in the slots above the newborn's shoulders. A nurse is providing discharge teaching to the parents of a newThe nurse should instruct the parents to place the shoulder harborn about car seat safety. Which of the following instructions ness in the slots that are at or just below the newborn's shoulders. should the nurse include? B. Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. C. Place the newborn at a 60° angle in the car seat. The nurse should instruct the parents to position the newborn at a 45° angle to minimize the risk of airway obstruction from slumping forward. D. Place the newborn in a b A. Restrict hourly fluid intake to 150 mL/hr. B. Have calcium gluconate readily available. C. Assess deep tendon reflexes every 6 hr. D. Monitor intake and output every 4 hr. Answer: The nurse should have calcium gluconate readily available A. Restrict hourly fluid intake to 150 mL/hr. The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine output should be 30 mL/hr or greater. B. Have calcium gluconate readily available. 14 / 16 The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. A nurse is caring for a client who has preeclampsia and is receiv- C. Assess deep tendon reflexes every 6 hr. ing a continuous infusion of magnesium sulfate IV. Which of the The nurse should assess deep tendon reflexes every 1 to 4 hr following actions should the nurse take? during continuous infusion of magnesium sulfate. D. Monitor intake and output every 4 hr. The nurse should monitor intake and output hourly for clients who are receiving a continuous infusion of magnesium sulfate. The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. A nurse is preparing to perform Leopold maneuvers for a client. Second, the nurse should determine the location of the fetal back. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in order of performance. Use all Third, the nurse should palpate for the fetal part presenting at the the steps.) inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head. A. Shortness of breath when climbing stairs B. Swelling of feet and ankles at the end of the day C. Headache that is unrelieved by analgesia D. Braxton Hicks contractions Answer: Headache that is unrelieved by analgesia A. Shortness of breath when climbing stairs Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected manifestation at 35 weeks of gestation. A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to B. Swelling of feet and ankles at the end of the day the provider. Which of the following manifestations should the Swelling of feet and ankles is due to the enlarging uterus interfernurse include? ing with blood return to the heart and is an expected manifestation at 35 weeks of gestation. C. Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. D. Braxton Hicks contractions Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected manifestation at 35 weeks of gestation. A. Massage the client's fundus. B. Insert an indwelling urinary catheter. C. Administer oxygen at 10 L/min. D. Elevate the client's right hip. Answer: Massage the client's fundus. A nurse on a postpartum unit is caring for a client who is expeA. Massage the client's fundus. riencing hypovolemic shock. After notifying the provider, which of The greatest risk to the client is hemorrhage. Therefore, the next the following actions should the nurse take next? action the nurse should take is to massage the client's fundus to expel clots and promote contractions. B. Insert an indwelling urinary catheter. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. 15 / 16 C. Administer oxygen at 10 L/min. The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion. However, this is not the next action the nurse should take. D. Elevate the client's right hip. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take. A. Just above the umbilicus B. Just above the symphysis pubis C. The right lower quadrant D. The left lower quadrant Answer: Just above the symphysis pubis A. Just above the umbilicus The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound B. Just above the symphysis pubis stethoscope in which of the following locations to begin assessing At the end of the first trimester of pregnancy, the client's uterus for the fetal heart tones (FHT)? is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. C. The right lower quadrant At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the right lower quadrant. D. The left lower quadrant At the end A. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex Answer: Substernal chest retractions while sleeping A. Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? B. Murmur at the left sternal border An audible murmur heard at the left sternal border is an expected manifestation in newborns. C. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. D. Positive Babinski reflex A positive Babinski reflex is an expected manifestation in newborns. This reflex is elicited when a newborn's sole is stroked with a finger upward along the lateral aspect of the sole and then across the ball of the foot and, in response, the t 16 / 16