Preview Extract
ATI MATERNAL NEWBORN PROCTORED 2019
A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the
following clinical findings should the nurse identify as an indication of postpartum infection?
Answer: Unilateral breast pain
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the
following findings should the nurse report to the provider?
Answer: Urine protein of 3+
A nurse is providing teaching about the expected effects of magnesium sulphate to a client who
is at 28 weeks gestation and has preeclampsia. Which of the following responses by the nurses is
appropriate?
Answer: "This medication prevents seizures"
A nurse is teaching a prenatal class regarding false labor. Which of the following information
should the nurse include?
Answer: Your contractions will become temporarily regular
A nurse manager is revising a maternal unit policy to ensure proper identification of newborns.
Which of the following should the nurse include in the policy?
Answer: Obtain an imprint of the infants feet prior to taking him into the nursery
A nurse is caring for a client who delivered by caesarean birth 6 hrs. ago. The nurse notes a
steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the
following actions should the nurse take?
Answer: Administer 500 mL lactated ringer's IV bolus
A nurse is providing discharge instructions to a client who is postpartum and has engorged
breasts. Which of the following nonpharmacological comfort measures should the nurse include
in the teaching?
Answer: Apply cabbage leaves
A nurse is calculating the estimated date of birth using Nagele's rule for a client who is pregnant
and whose last menstrual cycle started June 21. Which of the following is the estimated date of
delivery in the next year?
Answer: March 28
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of
the following actions should the nurse take?
Answer: Prepare the client for what to expect the fetus to look like.
A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying
in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms,
the mother states, "No, the baby is too tired to be held." Which of the following actions should
the nurse take?
Answer: Demonstrate how to hold the newborn and allow the client to practice
A nurse is caring for a client who is in labor. Which of the following findings should prompt the
nurse to reassess the client.
Answer: Abnormal Fetal Heart Rate (FHR)
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the
following findings should the nurse report to the provider?
Answer: Platelet count 60,000/mm HELLP Syndrome
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which
of the following actions should the nurse take?
Answer: Measure from the upper border of the symphysis pubis to the upper border of the
fundus
A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of
the following recommendations should the nurse make to help relieve this common discomfort
of pregnancy?
Answer: Drink 2 to 3 L of water each day
A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using
an ultrasound device, the nurse hears blood rushing through the umbilical vessels in
synchronization with the fetal heartbeat. Which of the following terms should the nurse use to
document this finding?
Answer: Funic souffle
A nurse manager in a newborn nursery is reviewing infection control procedures with a group of
newly hired nurses. Which of the following instructions should the nurse manager include in the
teaching?
Answer: Place newborn bassinets at least 3 feet apart
A nurse is caring for a client who is receiving magnesium sulphate by continuous IV infusion.
The nurse notes a respiratory rate of 8/min and absent DTR's. Which of the following
medications should the nurse administer?
Answer: Calcium gluconate
A nurse is caring for a client who is 8 hrs. postpartum following vaginal delivery and is unable to
void. Which of the following interventions should the nurse use to promote voiding?
Answer: Insert an indwelling urinary catheter
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses
about maternal cytomegalovirus. Which of the following information should the nurse manager
include in the teaching?
Answer: Transmission can occur via the saliva and urine of the newborn
A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the
following is the initial laboratory test used to evaluate this condition?
Answer: Urine ketones
A nurse in a prenatal clinic is reviewing the lab results for a client who is at 12 weeks of
gestation. Which of the following actions should the nurse take (EXHIBIT QUESTION)
Answer: Administer ceftriaxone IM
A nurse is teaching a client about the basal body temperature method of contraception. Which of
the following statements should the nurse include in the teaching?
Answer: "You should take your temperature before getting up for the day."
A nurse is providing education to a client who is to receive misoprostol for induction of labor.
Which of the following instructions should the nurse include in the teaching?
Answer: "You will lie on your side for 40 minutes after I administer the medication
A nurse is planning care for a client in the postpartum unit. Which of the following goals should
the nurse identify for the client to accomplish during the taking-in phase of postpartum
adjustment?
Answer: The client will have adequate nutritional intake
A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has
preeclampsia. Which of the following instructions should the nurse include in the teaching?
Answer: "Count your baby's movements daily."
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B
streptococcus-haemolytic (GBS). The client is multigravida and multipara with no history of
GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the
following is an appropriate response by the nurse?
Answer: "We need to know if you are positive for GBS at the time of delivery."
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following
clinical findings should the nurse report to the provider
Answer: Transient circumoral cyanosis
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of
the following findings should the nurse expect?
Answer: Cool, clammy skin
A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy.
Which of the following statements should the nurse make?
Answer: "You should take 600 micrograms of folic acid per day."
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for
labor induction. Which of the following interventions should the nurse include in the plan?
Answer: Increase the infusion rate every 30-60 min
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24
weeks of gestation. Which of the following information should the nurse include?
Answer: "You should expect your uterus to double in size."
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client.
Which of the following actions should the nurse take?
Answer: Verify that the informed consent is obtained prior to administration
A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory
disease. Available is metronidazole 500 mg tablets. How many tablets should the nurse
administer? (Round to nearest whole number)
Answer: 4 tabs
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should
the nurse recommend for an interdisciplinary care conference?
Answer: A client who is at 35 weeks of gestation and has a biophysical profile of 6
A nurse is planning to teach a group of clients who are pregnant about breastfeeding after
returning to work. Which of the following information should the nurse include in the teaching?
Answer: "Breast milk can be stored in a deep freezer for 12 months."
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord.
Which of the following clinical findings should the nurse expect?
Answer: Facial petechiae
A nurse is assessing a newborn upon admission to the nursery. Which of the following findings
should the nurse expect?
Answer: Chest circumference 2 cm (0.8 in) smaller than the head circumference
A nurse is assisting with precipitous delivery of a term newborn. After the head emerges, the
nurse palpates the cord around the newborn's neck. Which of the following actions should the
nurse take?
Answer: Slip the cord over the newborn's head
A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell
device. Which of the following interventions should the nurse include in the plan of care?
Answer: Monitor for bleeding every 15 min for the first hour
A nurse is providing discharge instructions to a client who is 24 hrs. postpartum and has decided
not to breastfeed. Which of the following instructions should the nurse include in the teaching?
Answer: "Apply ice packs to your breasts using a 15 minute on, 45 minutes off schedule."
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hours
postpartum and has a boggy uterus. For which of the following assessment findings should the
nurse withhold the medication?
Answer: Blood pressure 142/92 mm Hg
A nurse is caring for four newborns. Which of the following findings should the nurse report to
the provider?
Answer: A newborn who has a high-pitched cry with exaggerated Moro reflex
A nurse in a provider's office is caring for a 20-year old client who is at 12 weeks of gestation
and requests an amniocentesis to determine the gender of the fetus. Which of the following
responses should the nurse make?
Answer: "This procedure determines if your baby has genetic or congenital disorders."
A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain
following the administration of oxycodone/acetaminophen. Which of the following actions
should the nurse take first?
Answer: Assess the client's perineal area for swelling
A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal
heart rate on the external fetal monitor. After placing the client in a side-lying position, which of
the following actions should the nurse take?
Answer: Administer oxygen via a face mask
In severe forms of epispadia, what is often associated with it?
Answer: bladder exstrophy where bladder develops outside of the body
A nurse is reviewing the laboratory report of a client who is 24 hrs. postpartum vaginal delivery.
The client has a haemoglobin level of 9.0 g/dL and haematocrit of 25%. Which of the following
actions should the nurse take?
Answer: Initiate IV access for isotonic solution with an 18-gauge catheter
A nurse is caring for a client who is receiving magnesium sulphate by continuous IV infusion for
severe preeclampsia. Which of the following findings should the nurse report to the provider?
Answer: Urine output 20 mL/hr.
A nurse is performing a heel stick on a newborn. Which of the following actions should the
nurse take?
Answer: Use an automatic puncture device on the heel
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the
following actions should the nurse take first?
Answer: Assist the client to the bathroom
A nurse is providing teaching about increasing dietary fibre to an antepartum client who reports
constipation. Which of the following food selections has the highest fibre content per cup?
Answer: Oatmeal
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for
which of the following complications?
Answer: Haemorrhage
A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The
nurse should recognize that pregnancy is a contraindication to the administration of which of the
following medications?
Answer: Isotretinoin
A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a
left occipital anterior position (LOA). On which of the following sites should the nurse place the
external fetal monitor to hear the point of maximum impulse of the FHR?
Answer: Place the fetal monitor on the bottom left box
A nurse is reviewing the Immunization status of a client who is pregnant. The nurse should
inform the client that it is safe for her to receive which of the following immunizations during
pregnancy?
Answer: Tetanus
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of
the following findings should the nurse report to the provider?
Answer: 180 mg/dL
A nurse is receiving report on four postpartum clients. Which of the following clients should the
nurse plan to attend to first?
Answer: A client who has hyporeflexia while receiving IV magnesium sulfate
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hrs. ago.
The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the
client is at risk for which of the following conditions?
Answer: Postpartum hemorrhage
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which
of the following instructions should the nurse include?
Answer: Allow the baby to feed at least every 3 hrs.
A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates
a complication?
Answer: Hypotonic uterus
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hrs. ago. Which
of the following findings place the client at risk for postpartum hemorrhage? (Select all that
apply)
Answer: Labor induction with oxytocin
History of uterine atony
A nurse is assessing a full-term newborn. Which of the following findings should the nurse
report to the provider?
Answer: Heart rate 72/min
A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence
syndrome. Which of the following findings indicates narcotic withdrawal?
Answer: Excessive crying
A client and her partner ask the nurse for information about permanent contraception. Which of
the following statements should the nurse include in the counseling
Answer: "Most sterilization procedures are considered irreversible"
A nurse is providing discharge teaching to a client following tubal ligation. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: Ovulation will remain the same
A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse
should anticipate which of the following tests to assess for fetal lung maturity?
Answer: Lecithin/sphingomyelin ratio
A nurse is assessing a newborn who is 2 hrs. old. Which of the following findings should the
nurse report to the provider?
Answer: Single transverse palmar crease bilaterally
A nurse is assessing a newborn following a vaginal delivery. Which of the following findings
should the nurse report to the provider
Answer: Bulging fontaneles
A nurse is providing discharge teaching to the parent of a newborn about surgical site care
following circumcision using a clamp technique. Which of the following statements by the
parent indicates understanding?
Answer: I will apply petroleum jelly to area with each diaper change
A nurse is caring for a client who Is in the first stage of labor & the fetal head is in a posterior
position. The client reports pressure and pain in her lower back. Which of the following nonpharmacological comfort measure should nurse suggest first?
Answer: Counter pressure
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus
for pain. Which of the following findings should the nurse report to the provider following this
medication
Answer: Moderate fetal heart rate variability
A nurse is discussing family planning with a client who has a history of DVT. The nurse should
inform the client that this condition is a contraindication for which of the following birth control
methods?
Answer: Oral contraceptive
A nurse is caring for a newborn. Which of the following assessment findings should indicate to
the nurse that suctioning of the nasopharynx is needed?
Answer: The newborn is beginning to cough
A nurse is providing teaching to the parents of a newborn about the plastic bell circumcision
technique. Which of the following info should the nurse include?
Answer: Yellow exudate will form at the surgical site in 24 Hours
A nurse in a prenatal clinic is discussing quickening with a client who is in the first trimester of
her first trimester of her first pregnancy. Which of the following statements by the client
indicates understanding of the teaching
Answer: I will feel movement at about 16-20 wk
