Preview Extract
ATI Maternal Newborn 2023/2024 GRADED A LATEST
A nurse is caring for a client who has uterine atony and is experiencing pp haemorrhage the
following actions is the nurse's priority?
Answer: Massage the clients fundus
A nurse is caring for a client who is to receive oxytocin to augment her labor. which of the
following findings contraindicates the initiation of the oxytocin infusion and should be reported
to the provider
Answer: late decelerations
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations
should the nurse expect?
Answer: blurred vision
Explanation: due to dec blood flow to retina
severe preeclampsia would have >500 mg proteinuria
can have hyperactive reflexes of 3+
A nurse is assessing a client who is 1 day PP and has vaginal hematoma. Which of the following
manifestations should the nurse expect?
Answer: vaginal pressure
Explanation: due to blood that leaked into the tissues
A nurse is caring for a client who is at 36 W of gestation and has a positive contraction stress
test. the nurse should plan to prepare the client for which of the following diagnostic tests?
Answer: Biophysical Profile (BPP)
a nurse is providing teaching to a client who is 40 weeks of gestation and has a new prescription
of misoprostol. which of the following instructions should the nurse include in the teaching?
Answer: "I can administer oxytocin 4 hours after the insertion of the medications"
Explanation: oxytocin can be administered following misoprostol for clients who have cervical
ripening and have not begun labor.
A nurse is assessing 4 newborn. which of the following findings should the nurse report to the
provider.
Answer: a newborn who is 18 hr old and has an axillary temp 37.7 degrees Celsius (99.9).
a nurse is caring for a client who is 30 weeks of gestation and has a prescription for mag sulphate
IV to treat preterm labor. the nurse should notify the provider of which of the following?
a. nausea
b. urinary output of 40 ml/hr
c. respiratory rate 10/min
d. client reports feeling flushed
Answer: respiratory rate 10/min
A nurse is teaching a client who is 10 weeks gestation about nutrition during pregnancy. which of
the following statements by the client indicates an understanding of the teaching?
a. increase protein to 60 g
b. drink 2L of water each day
c. increase overall daily caloric intake by 300 calories
d. I should take 600 micrograms of folic acid each day"
Answer: "I should take 600 micrograms of folic acid each day"
Explanation: protein should be 71g each day during 2nd and 3rd trimester
should consume 3L of water a day
340 calcium during second and 452 calcium during 3rd
A nurse is assessing a late preterm newborn. which of the following manifestations is an
indication of hypoglycaemia?
a. hypertonia
b. increase feeding
c. hyperthermia
d. resp distress
Answer: respiratory distress
Explanation: late preterm newborn are at an in risk for hypoglycaemia due to dec glycogen
stores and immature insulin secretion. Resp distress is a manifestation of hypoglycemia. other
manifestations include abnormal cry, jitteriness, poor feeding, apnea, and seizures
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation:
a. 1 hr glucose tolerance of 120
b. haematocrit 34%
c. fundal height measurement of 30
d. FHR of 110
Answer: fundal height measurement of 30
Explanation: not 1 hr normal range, 130-140 or > is a positive test
haematocrit normal >33%
FHR normal 110-160BPM
nurse is caring for a client who is scheduled to receive Contin IV infusion of oxytocin following
vaginal birth. which of the following assessment findings should the nurse monitor to evaluate
the effectiveness of the med?
Answer: fundal consistency
A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. clients history
includes BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of
9lb and 3 oz. Which of the following lab values should the nurse expect to collect?
a. maternal serum alpha-fetoprotein
b. pregnancy assoc plasma protein A
c. chorionic villus sampling .
d. HbA1c
Answer: HbA1c
Explanation: measures the average plasma glucose concentration over the 12 weeks preceding
the test. at risk for impaired glucose metabolism and should be screened at the end of the 1st
trimester.
a nurse is providing discharge instructions for a client who had a c-section 4 days ago.
haemoglobin is 9.2 and the provider prescribed iron supp. Which of the following foods should
the nurse recommend to help in the clients iron intake?
a spinach
b. citrus fruit
c. milk
d. whole-grain bread
Answer: citrus fruit
Explanation: foods high vitamin c help inc the absorption of iron. includes citrus fruits,
strawberries, melons, and tomatoes
a nurse is discussing potential complications of newborn hypothermia. which of the following
complications should the nurse include?
a. tachycardia
b. hypoglycaemia
c. flushed skin
d. generalized petechiae
Answer: hypoglycemia
a nurse is teaching a client who is pp and breastfeeding which of the following statements should
the nurse include?
a. wait 3 months before sex
b. do not need to use contraception until you are 4 months
c. overproduction of vaginal lubricant
d. reduction in sexual interest could indicate pp depression
Answer: reduction in sexual interest could indicate pp depression
nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings
should the nurse expect?
a. elevated serum potassium level
b. rapid weight gain
c. peripheral edema
d. presence of ketones in urine
Answer: presence of ketones in the urine
Nurse caring for PP client 8 hr after delivery. which of the following factors places client at risk
for uterine atony? select all that apply
a. mag sulphate infusion
b. distended bladder
c. oxytocin infusion
d. prolonged labor
e. small for gestational age newborn
Answer: Mag sulphate infusion
Explanation: distended bladder prolonged labor
A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence
syndrome (NAS). which of the following actions should the nurse take?
a. swaddle infant with arms and legs extended
b. admin naloxone iM
c. avoid eye contact during feedings
d. discourage mother from handling the infant during the withdrawal phase
Answer: avoid eye contact during feedings
Explanation: infants with NAS have difficulty processing multiple forms of stimulation and can
quickly become frustrated.
which of the following hormones plays a key role in preventing miscarriage?
Answer: progesterone
Explanation: maintains endometrium and has a relaxant effect on the uterus so that the fetus is
not expelled (estrogen levels rise at the end of pregnancy to prepare for the onset of labor)
nurse teaching a client about vacuum assisted vaginal delivery. which of the following statements
should the nurse identify that the client understands the information?
a. Babys head will be cone shaped
b. Dr performed this because I did not dilate past 6 cm
c. performed bc haemoglobin was low
d. baby is at a higher risk of developing jaundice
Answer: baby is at a higher risk of developing jaundice
Explanation: bruises caused by the device dissipate
Nurse assessing client at 36 W. which of the following is a manifestation the nurse should
recognize as a prenatal complication and report?
a. varicose veins
b. double vision
c. leukorrhea
d. flatulence
Answer: double vision
planning care for 4 high risk newborns who were discharged yesterday. which of the following
newborns should the nurse plan to care for first?
a. 1 week old who needs another phenylketonuria screening
b. 4 day old who has elevated bill and requires phototherapy
c. 10 day old who is small for gestational age and requires daily weights
d. 2 week old born at 35 weeks and weighs 5lb at discharge
Answer: 4 day old who has elevated Bili and requires phototherapy
Teaching about epidural anaesthetic for labouring client. which of the following should the nurse
include?
a. newborn resp depression at birth
b. impaired ability of neonate to maintain body temp
c. impaired placental perfusion
d. dec FHR variability
Answer: impaired placental perfusion
Explanation: maternal hypotension can occur when mom receives epidural or spinal can cause
dec blood flow to placenta
what suggests newborn is post mature?
a. pale translucent skin
b. nails extending over fingers
c. weak gag reflex
d. thin covering of fine hair on shoulders and back
Answer: nails extending over fingers
Teaching about toxoplasmosis. which of the following instructions should the nurse include?
a. to prevent get the MMR vaccine
b. avoid gardening during pregnancy to dec risk
c. will get body rash if you are infected
d. transmitted through a bite from an infected mosquito
Answer: avoid gardening during pregnancy to dec risk
Explanation: potentially teratogenic to fetus, spread by contact with cat feces which can be in
garden areas. transmitted through uncooked meat
nurse teaching at 13 weeks about incompetent cervix with cervical cerclage. which of the
following statements indicates an understanding of the teaching?
Answer: "Cervical cerclage prevents preterm birth."
Nurse is reviewing the medical record for a client who is 39 weeks and has polyhydramnios.
what should be expected?
a. fundal height of 34cm.
b. total pregnancy weight of 3.6kg
c. gestational hypertension .
d. fetal gastrointestinal anomaly
Answer: fetal gastrointestinal anomaly
Explanation: excessive amniotic fluid can cause gastro intestinal malformations and
neurological disorders
A nurse is providing education to a female client of child-bearing age. the nurse should state
which of the following structures expels the mature ovum?
a. blastocyst
b. fallopian tube
c. corpus luteum
d. Graafian follicle
Answer: Graafian follicle
nurse reviewing lab findings of a 24-hour old newborn. Which of the following should be
reported?
a. haemoglobin 12
b. plt count 200,000
c. total bilirubin 4mg/dL
d. glucose 50 mg/dL
Answer: haemoglobin 12
Explanation: below ref rang of 14-24 g/dL
A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the
following findings should the nurse identify as a potential complication of oxygen therapy?
Answer: retinopathy
Explanation: o2 therapy can cause retinopathy of prematurity esp in preterm newborns.
vessels grow abnormally from the retina into the clear gel that fills the back of the eye, can
reduce vision or result in complete blindness.
Client is in 2nd stage of labor. FHR indicates multiple variable decelerations. What action should
the nurse take?
a. prepare an amnioinfusion
b. place client in supine position
c. administer oxygen 2L/ min via NC
d. give a glucocorticoid steroid
Answer: prepare an amnioinfusion
which of the following findings should the nurse plan to instruct the client to report
immediately?
a. vaginal leukorrhea
b. SOB
c. swelling of face and fingers
d. lower back pain
Answer: swellings of the face and fingers
client is 34 weeks gestation and has a cardiac disorder. Nurse should notify the provider about
which of the following assessment findings?
a. frequent cough
b. shoes do not fit anymore
c. weight gain of 2lb in 2 weeks
d. leg cramps in the evening
Answer: frequent cough
Explanation: can be a sign of cardiac decompensation
what is erythromycin given for prophylaxis against?
Answer: ophthalmia neonatorum
prevent gonorrhea and chlamydia in newborns
client with active herpes should receive what?
Answer: acyclovir
metronidazole is given for
Answer: bacterial vaginosis
full term newborn and eliciting the more reflex. which of the following movements are
expected?
a. thumb and forefinger forming a c
b. legs extending before pulling upward
c. arms and legs adducting
d. arms falling backward after startling
e. head turning to the right
Answer: thumb and forefinger forming a c
legs extending before pulling upward
Providing education to a client at 32 weeks of gestation who has pruritis gravidarum. which of
the following pieces of info should be provided?
a. "you should inc your exposure to sunlight"
b. will need extensive dermo treatment
c. provider will schedule weekly lab testing to monitor your liver function
d. will prescribe isotretinoin cream
Answer: "you should inc your exposure to sunlight"
Explanation: pruritis gravidarum is a condition of pregnancy that causes gen itching without
presence of rash. this is due to the stretching of skin. exposure to sunlight can reduce itching.
nurse is providing pp discharge instructions for a client who is breastfeeding. "I’ve heard that I
can't use any birth control until I stop breastfeeding"
a. you will not get pregnant while breastfeeding
b. birth control pill with only estrogen is okay
c. condoms are the only method
d. A progestin-only pill or injection for use while breastfeeding
Answer: A progestin-only pill or injection for use while breastfeeding
Explanation: some recommend to wait till 6 weeks to start
indomethacin is used for
Answer: tocolytic for preterm labor
nurse is caring for client who is hypotensive following epidural. what following action should be
taken?
a. dec IV fluids
b. give 2L min via NC
c. place client in lateral position
d. admin indomethacin
Answer: place client in lateral position
Explanation: place client in lateral position increase uterine perfusion to fetus
13 weeks gestation and hyperemesis gravidarum. which of the following should the nurse
identify as the priority?
a. bp 90/52
b. ketones 2+
c. specific gravity 1.035
d. sodium 130
Answer: ketones 2+
Explanation: malnutrition, serious risk. indicates body is breaking down fat and protein stores
for energy and can’t provide fetus with nutrients.
L&D nurse is teaching a newly licensed nurse about intermitted auscultation of the FHR. which
should be included>
a. count FHR for 15 sec after contraction
b. palpate and count the maternal radial pulse while listening to the FHR
c. place listening device over fetal chest to hear the FHR
d. Percuss the maternal abdomen to verify position of fetus
Answer: palpate and count the maternal radial pulse while listening to the FHR
Nurse is planning care for a client who is PP and has a cardiac disease. which prescription
requires clarification?
a. monitor I &O
b. initiate high fibre diet
c. weigh client weekly
d. imitate bed rest
Answer: weigh client weekly
Explanation: weigh client weekly should be daily to monitor for fluid overload
nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. nurse should
monitor for following potential adverse effects?
a. diarrhoea
b. thromboembolism
c. fatal asphyxia
d. oliguria
Answer: fetal asphyxia
Explanation: fetal asphyxia oxytocin may cause tachysystole, which can lead to uteroplacental
insuff. inadequate oxygen transfer to the placenta will result in fetal asphyxia.
Nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed hep
B vaccine, vit K, and an antiretroviral regimen. the plan of care indicates the newborns mother is
HIV-positive and plans to breastfeed. which of the following should be addressed?
a. hep B vaccine
b. antiretroviral regimen
c. vitamin K
d. breastfeeding
Answer: breastfeeding
Explanation: HIV can be transmitted through breastmilk
A nurse is planning care for a client who is at 35 weeks gestation. which of the following lab
tests should the nurse obtain?
a. rubella titer
b. blood type
c. Group B strep to
d. 1 hour glucose tolerance test
Answer: Group B stretto
Explanation: rubella is done at the first visit
blood type is done at the first visit
1 hour glucose is done 24-28 weeks
Client is in labor and asks her partner to perform effleurage. client has monitor belt on for fetal
monitoring. which of the following instructions should the nurse provide to the client's partner.
a. lightly stroke the upper thighs
b. steadily apply pressure to the sacrum
c. gently massage the mid-abdominal area
d. firmly squeeze both hips
Answer: lightly stroke the upper thighs
Explanation: efflurage involves light strokes or massaging the abdomen in rhythm to help
breathing and to relieve lb or pain.
client has oligohydramnios. which of the fetal anomalies should the nurse expect?
a. atrial septal defect
b. renal agenesis
c. spina bifida
d. hydrocephalus
Answer: renal agenesis
Explanation: oligohydramnios is volume of amniotic fluid is 45
uterine fibroids may cause:
Answer: pp hemorrhage
McRoberts maneuver to relieve should dystocia. The nurse should include:
a. position client on hands and knees while in bed
b. flex client's legs apart and raise her knees to her abdomen
c. apply gentle pressure on the client's fundus while she is lying supine
d. push the fetus' anterior shoulder under the symphysis pubis externally
Answer: flex client's legs apart and raise her knees to her abdomen
Explanation: flex knees apart which rotate pubic bone anteriorly which releases the shoulder
client in labor who received an epidural analgesia. blood pressure is 88/50 and FHR shows late
decels which of the following actions should the nurse take?
a. assist client to the bathroom
b. inc rate of primary IV infusion
c. position in semi fowlers
d. provide glucose via oral hydration or IV
Answer: inc rate of primary IV infusion
prior to receiving a spinal anaesthetic what should the nurse do?
a. infuse 500 ml bolus of NS
b. assess FHR for 10 min prior
c. position client upright on edge of bed
d. monitor vitals every 15 min after
Answer: infuse 500 ml bolus of NS
Explanation: offset potential of hypotension
What should be increased in daily diet during pregnancy?
Answer: A. iron
nurse is caring for a client at 34 weeks who presents with vaginal bleeding. what indicates if its
placenta previa or abruptio placenta?
a. uterine tone
b. FHR
c. BP
d. amount of bleeding
Answer: uterine tone
Explanation: placenta previa-relaxed soft painless abruptio firm board-like and pain present
when the uterus is relaxed, soft, painless the bleeding is caused by
Answer: placenta previa
indication of anaemia Hct <
Answer: 33%
Nurse is providing education about the newborn skin care, what should be included?
a. gently retract the foreskin to wash the glans with soap and water
b. sponge bath the newborn every other day
c. use antimicrobial soap
d. bathe the newborn between 115 -120
Answer: sponge bath the newborn every other day
human chorionic gonadotropin (hCG)
Answer: excreted by placenta and promotes excretion of progesterone and estrogen
client at 37 weeks gestation and a biophysical profile with a total score of 4. what should be
anticipated?
a. DC the client home
b. administer betamethasone
c. perform an amnioinfusion
d. prepare for delivery of the infant
Answer: prepare for delivery of the infant
Explanation: 6 or < indicates delivery considered
Nurse caring for a client who experiences a SROM and has prolonged decelerations on the fetal
monitor. Which condition should the nurse expect?
a. uterine rupture
b. placental abruption
c. prolapsed umbilical cord
d. amniotic fluid embolus
Answer: prolapsed umbilical cord
is having a male child and expresses concern for possible haemophilia. client is a carrier of the
gene mutation
a. 25%
b. 50%
c. 75%
d. 100%
Answer: 50%
Explanation: x-linked recessive
female clients have a 50% chance of giving it to their children male will have the disorder
nurse in prenatal clinic who is caring for a client who is pregnant and experiencing episodes of
maternal hypotension. client asks what causes these episodes. what should the nurse say?
a. inc in blood volume
b. due to pressure from the uterus on the diaphragm
c. due to the weight of the uterus on the vena cava
d. due to increased cardiac output
Answer: due to the weight of the uterus on the vena cava
Explanation: occurs when laying in supine position and the weight of the gravid uterus places
pressure on the vena cava dec venous blood flow to the heart
a nurse is caring for a client who is at 6 weeks gestation about common discomforts of
pregnancy. which of the following findings should the nurse include? select all
a. breast tenderness
b. urinary frequency
c. epistaxis
d. dysuria
e. epigastric pain
Answer: breast tenderness, urinary frequency, epistaxis
Nurse is reviewing for a biophysical test, what variables are considered?
a. fetal weight
b. fetal breathing movement
c. fetal tone
d. fetal position
e. amniotic fluid volume
Answer: fetal breathing movement, fetal tone, amniotic fluid volume
nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis.
the nurse should evaluate which of the following tests to assess the fetal lung maturity?
a. alpha fetoprotein
b. lecithin/sphingomyelin ratio
c. Keilhauer betake test
d. indirect coombs test
Answer: lecithin/sphingomyelin ratio
Explanation: AFP tests for neural tube defects
Keilhauer betake is used to detect fetal blood on cord sampling
indirect detects Rh antibodies in the mother's blood
marginal abruptio placentae, what are the risk factors?
a. fetal position
b. blunt trauma
c. cocaine use
d. maternal age
e. cigarette smoking
Answer: blunt trauma, cocaine use, cigarette smoking
nurse in antepartum is caring for a client who is 4 months gestation. client reports nausea and
vomiting and scant prune coloured discharge. no weight loss and fundal height larger than
expected. what following condition?
a. hyperemesis gravidarum
b. threatened abortion
c. hydatidiform mole
d. preterm labor
Answer: hydatidiform mole
nurse in antepartum clinic is assessing a client with a TORCH infection. what should be
expected?
a. joint pain
b. malaise
c. rash
d. urinary frequency
e. tender lymph nodes
Answer: joint pain, malaise, rash, tender lymph nodes
what medication would be given for a patient with gonorrhoea?
a. ceftriaxone
b. fluconazole
c. metronidazole
d. zidovudine
Answer: ceftriaxone
Explanation: ceftriaxone or doxycycline are given for 7 days
d is used to treat HIV/ AIDS
c. bacterial vaginosis
b. candidiasis
what infections should be treated during labor or immediately following?
a. gonorrhoea
b. chlamydia
c. HIV
d. Group B
e. TORCH infection
Answer: . gonorrhoea, chlamydia, HIV, Group B
Explanation: A & B are treated with erythromycin
c. mom is given Retrovir during labor
d. penicillin G or ampicillin is given
administering mag sulphate, what are signs of mag sulphate toxicity?
a. resp 33%
end of 1st trimester where will the nurse place the ultrasound to assess for the fetal heart tones?
a. above umbilicus
b. above symphysis pubis
c. RL quad
d. LL quad
Answer: above symphysis pubis
leopold maneuvers in order
a. palpate the fundus to identify fetal part
b. palpate for the fetal part presenting at the inlet
c. determine location of the fetus back
d. identify attitude of the head
Answer: palpate the fundus to identify fetal part
determine location of the fetus back
palpate for the fetal part presenting at the inlet
identify attitude of the head
nurse caring for a client who is at 41 weeks gestation and has a positive contraction stress test.
which of the following diagnostic tests should the nurse prepare the client?
a. percutaneous umbilical blood sampling
b. amnioinfusion
c. biophysical profile
d. chorionic villus sampling
Answer: biophysical profile
Explanation: positive contraction stress test means potential uteroplacental in suff. BPP uses
real time ultrasound to visualize physical and physiological characteristics of the fetus and
observe for fetal biophysical responses to stimuli
what test should be done if there is suspected placental abruption?
a. kleihauer-betke test
b. progesterone serum level
c. L/s ratio
d. maternal alpha fetoprotein
Answer: kleihauer-betke test
Explanation: to test if fetal blood is in maternal circulation also to see if rho gam is needed
Carboprost for pp hemorrhage may cause
a. HTN
b. hypothermia
c. constipation
d. muscle weakness
Answer: HTN,
Explanation: vasoconstrictor causes HTN
gonorrhea puts mom at risk for
a. excessive bleeding
b. oligohydramnios
c. PROM
d. proteinuria
Answer: PROM
Explanation: chorioamnionitis, preterm birth, neonatal sepsis and IUGR
caring for a client who has oligohydramnios. what fetal anomalies should be expected?
a. atrial septal defect
b. renal agenesis
c. spina bifida
d. hydrocephalus
Answer: renal agenesis
Explanation: oligo occurs when there is a renal system dysfunction or obstructive uropathy
absence of fetal kidneys will cause this.
what will a pregnant women take who has HIV?
Answer: zidovudine dec risk of transmission
37 weeks gestation. patient is rubella non immune positive for group A beta hemolytic
streptococci and blood type O neg
a. administer Rhogam
b. prescription for antibiotic until delivery
c. obtain a rubella after delivery
d. she will need to deliver via c-section
Answer: obtain a rubella after delivery
Explanation: Rhogam given at 28 weeks and 72 hours after baby if baby is Rh positive.
