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VATI RN Maternal Newborn 2023/2024
GRADED A 81 QUESTIONS AND ANSWERS WITH RATIONALE
A charge nurse is teaching a newly licensed nurse about substance use disorders during
pregnancy. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching?
Answer: Encourage client who are prescribed methadone to breastfeed.
Rationale:
The nurse should encourage clients who are prescribed methadone during pregnancy to
breastfeed their newborns to help with withdrawal symptoms.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following
findings is an indication the medication was effective?
Answer: Decreased frequency of contractions.
Rationale:
Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause
relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse should
identify that a decrease in frequency of contractions is an indication that terbutaline was
effective.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which
of the following actions should the charge nurse include in the teaching regarding situations
requiring an amniotomy?
Answer: Placing a fetal scalp electrode.
Rationale:
A fetal scalp electrode is attached to the presenting part of the fetus in order to provide accurate
continuous monitoring of the fetal heart rate. If the client's membranes are intact, the amniotic
sac must be artificially ruptured prior to attaching the electrode to enable access to the presenting
part.

A nurse is reviewing the medical record of a client who has preeclampsia prior to administering
labetalol. For which of the following findings should the nurse withhold the medication?
Answer: Heart rate 54/min
Rationale:
The nurse should identify that a heart rate of 54/min is below the expected reference range of 60
to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood
volume and increase tissue demands for oxygen. Bradycardia is a contraindication for the
administration of labetalol, an antihypertensive medication. Therefore, the nurse should withhold
the medication and notify the provider.
A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking
while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the
nurse should take to clear the airway obstruction.
Answer:
1.

Stand posterior to the client.

2.

Position arms under the client's axilla and across the client's chest.

3.

Place thumb-side of a clenched fist to the client's mid-sternum area.

4.

Initiate chest thrust to the client using a backward motion.

Rationale:
If the client becomes unconscious, the nurse should perform CPR and activate emergency
medical services.
A nurse is preparing to administer an opioid analgesic to a client who is in active labor. Which of
the following assessments should the nurse perform? (SATA)
Answer: Maternal blood pressure.
Rationale:
• Opioid analgesic can cause hypotension. The nurse should assess the clients blood pressure
before and after administering opioids.
Pain level.

• The nurse should assess the clients baseline pain level prior to administering pain medication
and again after administering pain medication to determine the effectiveness of the medication.
Opioid analgesic are indicated for the relief of moderate to sever labor pain.
Fetal heart rate.
• Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should
assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within
the expedited reference range and to have a baseline for future assessments. The nurse should
provide ongoing assessments of fetal heart rate throughout labor according to facility protocol.
A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of the
following findings should the nurse identify as a risk factor for developing preeclampsia?
Answer: Rheumatoid Arthritis.
Rationale:
The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus
erythematosus, increase a clients risk for developing preeclampsia.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for
deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor?
Answer: International normalized ratio (INR).
Rationale:
The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time(PT) is
also measure to regulate warfarin therapy. However, PT values are more difficult to interpret.
INR determined by multiplying the PT by a correction factor based on the specific
thromboplastin preparation used for the test, as a way of equalizing laboratory to laboratory
variations.
A nurse is monitoring a client who is in the active phase of labor and has an intrauterine pressure
catheter and fetal scalp electrode. Which of the following findings should the nurse expect?
Answer: Montevideo units (MVU) of 220 mm Hg.
Rationale:

The nurse should identify that an MVU of 220 mm Hg is within the expected range during the
active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of
labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated
by subtracting the baseline uterine pressure from the peak contraction pressure for every
contraction that occurs during a 10-min period. The nurse then adds the pressure produced by
each contraction during that time to determine the MVUs.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural
morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is
10/min. Which of the following actions should the nurse take first?
Answer: Administer oxygen by nonrebreather face mask.
Rationale:
The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to administer oxygen by nonrebreather mask to treat manifestations of respiratory
depression due to morphine administration.
A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of
the following clinical findings should the nurse expect?
Answer: Painless vaginal bleeding.
Rationale:
The placenta implants in the lower uterine segment, partially or completely covering the cervix.
With cervical changes, the placental blood vessels can tear, which results in bleeding.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings
should the nurse report to the provider?
Answer: Episodes of blurred vision.
Rationale:
Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased perfusion
to the retina cause visual disturbances, such as blurred vision, double vision, or dark spots in the
visual field.

A nurse is assessing a client who is at 8wks of gestation and has hyperemesis gravidarum. Which
of the following are findings of this condition? (SATA)
Answer:
1.

Tachycardia.

2.

Dry mucous membranes.

3.

Poor skin turgor.

Rationale:
Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte
imbalance, excessive weight loss, ketonuria, and nutritional deficiencies.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the
following results should the nurse identify as an indication of a prenatal complication?
Answer: BUN 30 mg/dL
Rationale:
Above the expected reference range of 10-20 mg/dL for a client who is pregnant. The BUN
typically decreases during pregnancy due to the increase in the glomerular filtration rate. The
nurse should identify that an elevated BUN is a manifestation of preeclampsia or HELLP
syndrome, potentially serous complications of pregnancy's.
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad in 15min.
The clients skin is cool and clammy to touch. Which of the following actions should the nurse
take first?
Answer: Firmly massage the fundus.
Rationale:
The greatest risk for a postpartum client who is experiencing excessive vaginal bleeding is the
development of hypovolemic shock, which can lead to coma and death. Uterine atony is a
frequent cause of excessive vaginal bleeding. Therefore, the first action the nurse should take is
to massage the clients fundus to encourage muscular contractions, which will decrease bleeding.

A nurse is caring for a client who is at 28wks of gestation and has received two doses of
terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to
report to the provider?
Answer: Heart rate: 132/min
Rationale:
The nurse should notify the provider of tachycardia greater than 130/min; therefore, this is the
priority finding. The client might also report chest discomfort, palpitations and have arrhythmias.
A nurse is providing teaching for a client who is 2wks postpartum and has mastitis. Which of the
following instructions should the nurse include in the teaching?
Answer: Apply moist heat to the affected breast.
Rationale:
The application of warm compresses prior to feeding or pumping promotes the flow of the breast
milk and assists to ensure complete emptying of the breast. This is important to prevent the
development of further complications such as the formation of a breast abscess or chronic
mastitis.
A nurse is teaching routine prenatal care to a group of clients who are pregnant. Which of the
following statements by a client indicates an understanding of the teaching?
Answer: I will have monthly prenatal visits for the first 28wks of pregnancy.
Rationale:
The initial visit should occur in the first trimester with monthly visits through week 28, and
every 2 weeks until week 36, and then every week until the birth of the newborn.
A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the
following statements should the nurse include in the teaching? (SATA)
Answer:
1.

You might have to have cultures for sexually transmitted infections prior to placement of

the device.
2.
device.

You might experience irregular spotting the first few months after placement of the

3.

You will need to sign informed consent prior to the procedure.

Rationale:
If the provider determines the client is at risk of STI they might require the collection of cultures
for STI prior to the placement of the IUD.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings
should the nurse report to the provider?
Answer: Epigastric pain.
Rationale:
This is a manifestation of preeclampsia. Other findings the nurse should report include severe
HA, Blurred vision, confusion, N&V, and decrease urinary output.
A nurse is assessing a client who is 6hrs postpartum, tachycardia, and has cool skin. The client
reports that they have been bleeding excessively. Which of the following actions should the nurse
take?
Answer: Initiate and infusion of oxytocin.
Rationale:
The nurse should identify that the client is exhibiting manifestations of hypovolemic shock,
which can be caused by uterine atony and is a medical emergency. The nurse should initiate an
infusion of 10-20 units of oxytocin, which is an oxytocic medication. This will cause the uterus
to contract and decrease bleeding.
A nurse is monitoring a client who is in active labor and observes a pattern of late decelerations
on the fetal monitor tracing. Which of the following findings should the nurse recognize as the
potential cause of the deceleration?
Answer: Fetal hypoxia
Rationale:
Late decelerations are caused by uteroplacental insufficiency or a decreased blood flow from the
uterus to the placenta during contractions. This results in a decreased supply of oxygen to the
fetus during the contraction. This pattern can be cause by a wide variety of reasons including

uterine tone, maternal hypotension, and disorders that affect the placenta such as maternal
diabetes, preeclampsia and post maturity.
A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling
acceptance of the newborn. Which of the following instructions should the nurse include in the
teaching?
Answer: The patent should plan to spend individual time with the older sibling.
Rationale:
To enhance and facilitate sibling acceptance of the newborn.
A nurse is caring for a newborn immediately following birth who has meconium-stained
amniotic fluid and exhibits good muscle tone and respiratory efforts. Which of the following
actions should the nurse take first?
Answer: Begin suctioning of mouth and nose.
Rationale:
The nurse should assess the newborns' condition at birth and suction the newborn's mouth and
nose with a bulb syringe based on the assessment findings. If the newborns respiratory status is
depressed, endotracheal suctions must be done as well to remove any meconium that has entered
the newborn's airways.
A nurse is teaching a client about iron supplementation during pregnancy. Which of the
following client statements indicates an understanding of the teaching?
Answer: I will be certain to consume 29 grams of fiber daily.
Rationale:
The client should consume a diet high in fiber and increase fluid intake to help reduce the
occurrence of constipation.
A nurse is performing a contraction stress test (CST) on a client who is at 40wks of gestation.
The results of the test indicate a negative CST. Which of the following actions should the nurse
take?
Answer: Allow the labor to progress naturally.

Rationale:
The absence of late deceleration (a negative results) indicates that the fetus will probably tolerate
labor; therefore, the nurse should allow the labor to progress naturally.
A nurse is caring for a newborn who was delivered by cesarean birth 1 min ago and displays
some flexion of the extremities, is not cry, has irregular respiratory effort, and has a heart rate of
92/min. The nurse notes grimacing but no crying when rubbing the soles of the newborn's feet.
The newborn's skin color is pink with blue extremities. What is the correct Apgar score?
Answer: 1 min is 5.
Rationale:
The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone,
reflex irritability, and color. For this newborn, the heart rate of 92/min scores 1, irregular
respiratory effort scores 1, some flexion of the extremities scores 1, grimacing scores 1, and pink
body with blue extremities scores 1, resulting in a total Apgar score of 5.
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level
in the abdomen a nurse should expect to find the client's uterus when assessing the fundus.
Answer: The nurse should expect to find the client's uterus at or just below the level of the
umbilicus 2 hours postpartum.
Rationale:
Immediately after birth, the fundus should be firm, midline with the umbilicus, and
approximately 2cm below the level of the umbilicus. At 12hrs postpartum the nurse should
palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs the fundus should descend
approximately 1-2cm (0.4-0.8in) It should be halfway between the symphysis pubis and the
umbilicus by 6 days postpartum.
A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic
pregnancy. Which of the following actions should the nurse take?
Answer: Wear two pairs of gloves when handling the medication.
Rationale:

Methotrexate is an antineoplastic agent that a pharmacist must prepare in a syringe under a
biologic safety cabinet and place in a sealed plastic bag. The nurse should wear two pairs of
gloves when removing the syringe from the bag, administering the medication, and disposing of
the syringe.
A nurse is completing a health history and assessment for a client who reports they are pregnant.
Which of the following findings is a presumptive sign of pregnancy?
Answer: Amenorrhea.
Rationale:
A client can present with amenorrhea for a variety of reasons besides pregnancy.
A nurse is caring for a client who is in active labor and is scheduled to receive epidural
anesthesia. Which of the following actions should the nurse take?
Answer: Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural
placement.
Rationale:
To prevent hypotension.
A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports
being positive for group B streptococcus (GBS) when screened at 36wks of gestation. Which of
the following actions should the nurse expect to take?
Answer: Administer IV antibiotic prophylaxis.
Rationale:
To decrease the risk of the neonate contracting a GBS infection, it is recommended that pregnant
clients who test positive for GBS receive antibiotics during labor.
A nurse is reviewing the results of a nonstress test for a client who is at 37wks of gestation.
Which of the following findings indicates a reactive nonstress test?
Answer: Fetal heart rate (FHR) accelerations occur with fetal movement.
Rationale:

A nonstress test measures the response of the FHR to fetal movement. Accelerations of the FHR
with fetal movement are a reassuring sign of fetal well being.
A nurse is providing teaching about nifedipine for a client who is at 34wks of gestation and has
gestational HTN. For which of the following adverse effects should the nurse instruct the client
to notify the provider?
Answer: Irregular heartbeat.
Rationale:
Cardiac arrhythmia is a potential life-threatening adverse effect of nifedipine. Therefore, the
client should report an irregular heartbeat to the provider.
A nurse is assessing a client who is in labor, Which of the following findings should the nurse
expect?
Answer: Decrease in blood glucose level.
Rationale:
Maternal metabolism, physical exertion, and delivery of the placenta can lead to a decreased
blood glucose level.
A nurse is assessing a newborn following a circumcision 48hrs ago. The nurse should identify
that yellow exudate covering the newborn's glans penis indicates which of the following?
Answer: Healing.
Rationale:
After 24hrs, yellow exudate usually forms over the glans penis and remains for the next 2-3 days.
It sometimes forms a crust, which is expected. The nurse should explain that the yellow film the
guardians will see is granulation tissue as the circumcision heals. The guardians should not
remove this tissue.
A nurse is performing an initial assessment during a client's first prenatal visit. The client states
that her last menstrual period began April 22. Use Nagele's rule to calculate the expected date of
birth (EDB).

Answer: Using Nagele's rule, the expected date of birth (EDB) would be January 29 of the
following year.
Rationale:
Begin with the first day of the clients last menstrual period, subtract 3 months, and add 7 days.
A nurse is assessing a newborn. Which of the following findings indicates a need to check the
newborn's blood glucose level for hypoglycemia?
Answer: Hypotonia
Rationale:
CNS findings of hypoglycemia include lethargy and hypotonia, as well as jitteriness, twitching,
poor feeding, temperature instability, apnea, respiratory distress, and seizures.
A nurse is teaching a class to clients who are pregnant. Which of the following topics should the
nurse include in the discussion about cesarean birth? (SATA)
Answer:
1.

Management of postpartum pain

The nurse should discuss with clients that they will have incisional pain associated with uterine
involution.
2.

Advantage of early ambulation post-surgical procedure.

Early ambulation following a cesarean birth facilitates circulation in the lower extremities,
preventing stasis, and assists with relieving gas pains.
3.

The need for an indwelling urinary catheter during delivery.

The nurse should place an indwelling urinary catheter prior to the cesarean birth to keep the
client's bladder empty and to avoid interference with the surgical procedure.
A nurse is providing teaching to a postpartum client about strategies to reduce the risk of
newborn abduction from the facility. Which of the following instructions should the nurse
include in the teaching?
Answer: Bring your newborn in the bassinet into the bathroom with you.
Rationale:

The client should wheel the newborn in the bassinet into the bathroom with her rather than leave
the newborn unattended. The nurse should instruct the client never to leave the newborn
unattended.
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has
postpartum hemorrhagic shock. Which of the following statements should the charge nurse
make?
Answer: The most accurate indication of organ perfusion is a clients urine output.
Rationale:
Output greater than 30 mL/hr. is an indication of adequate perfusion and oxygenation.
A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48hrs after
birth. Which of the following findings should the nurse report to the provider?
Answer: Depressed fontanels.
Rationale:
Sunken or depressed fontanels are a finding associated with dehydration of the newborn.
Additionally, dry oral mucosa, weight loss greater than 10%, and decreased urine output are
findings associated with dehydration.
A nurse is caring for a postpartum client who is breastfeeding her newborn and reports that her
nipples have become sore and cracked. Which of the following statements should the nurse
make?
Answer: Apply colostrum to the nipples after feeding to help them heal.
Rationale:
Colostrum and breast milk have healing properties and can help reduce soreness.
A nurse is receiving report on four newborns born in the past 12hrs. Which of the following
newborns should the nurse assess first?
Answer: A newborn who has an axillary temperature of 36°C (96.8°F).
Rationale:

Cold stress increases the newborn's need for oxygen and can deplete glucose stores. It also can
increase the newborn's respiratory rate and cause cyanosis. The expected axillary temperature for
the newborn averages 37°C (98.6°F) and ranges from 36.5°C (97.7°F) to 37.2°C (99°F).
A nurse is teaching a new guardian how to correctly use a car seat. Which of the following
statements by the guardian indicates an understanding of the teaching?
Answer: I should keep my baby in a rear-facing car seat until he is 2yrs old.
Rationale:
Or until the child reaches the maximum height and weight for the seat.
A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the
following actions should the nurse take?
Answer: Cleanse the puncture site with alcohol gauze prior to the procedure.
Rationale:
Or a facility-approved skin cleanser prior to the procedure to minimize the risk of infection.
A nurse is teaching a client who has hyperemesis gravidarum about dietary modifications. Which
of the following client statements indicates an understanding of the teaching?
Answer: I will eat small, frequent meals throughout the day.
Rationale:
The client should focus on eating small, frequent meals throughout the day and consuming foods
that are appealing.
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at
an increased risk for a fall?
Answer: A client who has an indwelling urinary catheter.
Rationale:
The client's required medical interventions, such as IVs and urinary catheters, increase the risk
for falls from tripping over tubing. The nurse should assist the client when getting out of bed and
ambulating to prevent an injury from a fall.

A nurse is caring for a client who is 3 days postpartum. Which of the following actions should
the nurse take?
Answer: Obtain a vaginal culture.
Rationale:
Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are
manifestations of endometritis, an infection of the lining of the uterus. The nurse should obtain a
vaginal culture using a sterile swab to collect the fluid from the client's vaginal cavity to identify
the organism.
A nurse is caring for a client who is in active labor and receiving epidural anesthesia. The client
reports feeling nauseated and experiences a blood pressure drop from 125/70 mm Hg to 90/50
mm Hg. Which of the following actions should the nurse take first?
Answer: Turn the client to a lateral position.
Rationale:
The greatest risk to this client is injury from maternal hypotension and decreased placental
perfusion; therefore, the first action the nurse should take is to place the client in a lateral
position to relieve the pressure on the vena cava and restore venous return.
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just
broke and my baby is breech." Which of the following actions should the nurse take first?
Answer: Check fetal heart tones.
Rationale:
A variation in fetal heart tones can occur due to a prolapsed umbilical cord. The risk of a
prolapsed cord is increased with noncephalic presentations when the membranes are ruptured.
Prolapse of the cord compromises circulation to the fetus.
A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of
the following nonpharmacological interventions should the nurse provide to manage the clients
pain?
Answer: Encourage the support person to apply sacral counterpressure.
Rationale:

Consistent pressure applied by the support person using the heel of the hand or fist against the
client's sacral area will lift the fetal head off the spinal nerves and provide relief of the pain in the
lower back.
A nurse is caring for a client who had a vaginal delivery 2hrs ago and is reporting increasing
perineal pain and pressure. The nurse examines the clients perineum and sees a 4cm (1.6in) area
of purplish discoloration with swelling. The nurse should interpret these findings as which of the
following?
Answer: A hematoma
Rationale:
A hematoma is a collection of blood in the connective tissue while the overlying skin or mucous
membranes remain intact. Hematomas develop from injury to soft tissue in spontaneous
deliveries, as well as forceps-and-vacuum-assisted deliveries. Small hematomas usually reabsorb
on their own, but large ones might require incision and ligation of bleeding vessels.
A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella
and received the rubella immunization. Which of the following statements by the client indicates
an understanding of the teaching?
Answer: I can breastfeed my baby even though I received this immunization.
Rationale:
According to the CDC, breastfeeding should not delay a client from receiving the rubella
immunization.
A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report
to the provider?
Answer: Generalized petechiae
Rationale:
Are pinpoint round spots that appear on the skin, which can indicate a clotting factor deficiency
or infection.

A nurse is preparing to administer methotrexate 1 mg/kg IM to a client who weights 110lbs and
is receiving care for an ectopic pregnancy. Available is methotrexate 25 mg/mL. How many mL
should the nurse administer?
Answer: The nurse should administer 2 mL of methotrexate.
Rationale:
The client weighs 110 lbs, which converts to 50 kg (110 lbs ÷ 2.2 lbs/kg). The required dose is
50 mg (1 mg/kg × 50 kg), and with a concentration of 25 mg/mL, the nurse should administer 2
mL (50 mg ÷ 25 mg/mL).
A nurse is caring for a 2 day old newborn who has a bilirubin level of 14 mg/dL and is to begin
phototherapy. Which of the following actions should the nurse take?
Answer: Monitor intake and output.
Rationale:
The nurse should monitor intake and output because phototherapy can increase the rate of
insensible water loss, which contributes to fluid loss and dehydration. The nurse should also
monitor the newborns fontanels. Hydration is achieved by breastfeeding or formula feeding the
newborn.
A nurse is monitoring a client who is receiving oxytocin to augment labor and observes a pattern
of late decelerations on the fetal monitor tracing. Which of the following actions is the nurse's
priority?
Answer: Position the client laterally.
Rationale:
Late decelerations occur because of uteroplacental insufficiency. First position the client in a
lateral position to improve oxygenation to the fetus.
A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to
treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an
indication that calcium gluconate was effective?
Answer: Respiratory rate 12/min -Respiratory depression is a manifestation of magnesium
sulfate toxicity.

Rationale:
Calcium gluconate is given to counteract the effects of magnesium sulfate toxicity, which can
cause respiratory depression. An improved respiratory rate of 12/min indicates effective reversal
of respiratory depression.
A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the
following interventions should the nurse include in the plan to manage the client's pain?
Answer: Encourage the client to listen to music
Rationale:
The nurse should implement nonpharmacological strategies to encourage relaxation and provide
pain relief. There are a wide variety of cutaneous and sensory measures that are simple to
implement during this stage of labor, such as music, rocking, breathing techniques, walking and
application of hot and cold packs.
A nurse is providing discharge instructions to the parents of a newborn about bathing. Which of
the following statements by the parent indicates an understanding of the instructions?
Answer: We will wash out newborn's face first.
Rationale:
Bathing should proceed from the cleanest part of the body to the most soiled areas. First, from
the eyes and face, then to the trunk and extremities, and then to the diaper area to prevent the
spread of infection or cross contamination.
A nurse is interviewing a client who is at 10wks of gestation. Which of the following statements
by the client should the nurse investigate further?
Answer: I just want to stay in bed all day because nothing interest me anymore.
Rationale:
Feelings of sadness marked by loss of interest in usual activities can indicate depression, which
is not a normal adaptation to pregnancy.
A nurse is planning to use a Doppler device to auscultate fetal heart tones (FHTs) for a client
who is at 12wks of gestation. Which of the following actions should the nurse plan to take?

Answer: Count the radial pulse of the client while auscultating FHTs.
Rationale:
The nurse should count the client's radial pulse while auscultating FHTs to differentiate it from
the fetal heart rate.
A nurse is providing teaching for a guardian regarding newborn care. Which of the following
statements by the guardian indicates understanding of the teaching?
Answer: I will use a rear-facing car seat for my baby for the first 2 years.
Rationale:
Infants should travel in rear-facing car seats until the age of 2 years old or until the child reaches
the height or weight requirements that are recommended by the manufacturer of the care seat.
A nurse is providing prenatal education to a client who is at 16wks of gestation. Which of the
following statements by the client indicated an understanding of anticipated body changes during
the second trimester?
Answer: I might notice a change in my skin coloring.
Rationale:
Skin pigmentation deepens during the second trimester of pregnancy due to actions of the
melanocyte-stimulating hormone.
A nurse is providing teaching to a client who is at 8wks of gestation about vaccines that are
administered during pregnancy. Which of the following vaccines should the nurse discuss with
the client?
Answer: Tetanus-diphtheira-acellular pertussis (Tdap) vaccine.
Rationale:
The CDC recommends that clients who are pregnant should receive the Tdap and seasonal
inactivated influenza vaccine with each pregnancy. Clients who are pregnant should avoid all
live or live attenuated immunizations due to potential for teratogenic effects in the fetus.

A nurse is collecting information about a health history for a client who requests a prescription
for a combined oral contraceptive (COC). Which of the following information should the nurse
identify as a contraindication for the use of a COC?
Answer: History of migraine with aura.
Rationale:
Contain both estrogen and progestin. These hormones can cause an increase in the risk for
thrombotic stroke for clients who have migraine w/aura. Safe for client to have migraines
without aura to use a COC if they have no other contraindications, such as a history of
estrogendependent tumors or coronary artery disease.
A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder
dystocia. Which of the following actions should the nurse take?
Answer: Position the client using the McRoberts maneuver.
Rationale:
Decreases shoulder dystocia. The nurse should flex the client's thighs sharply against their
abdomen, with their legs apart, to straighten the sacral area and rotate the symphysis pubis
toward the client's head.
A nurse is assessing a client who is at 32wks of gestation. Which of the following findings is an
indication of a potential prenatal complication?
Answer: Epigastric pain.
Rationale:
Indication of preeclampsia. Other indications of preeclampsia include abdominal pain, severe
HA, HTN, polyuria, and proteinuria.
A nurse is caring for a newborn who has hyperbilirubinemia and a new prescription for
phototherapy. Which of the following actions should the nurse plan to take?
Answer: Change the newborn's position every 2hrs.
Rationale:
Reposition the newborn every 2-3hrs during phototherapy. This will maximize exposure of the
skin to the light, enhancing the effectiveness of phototherapy.

A nurse is creating a plan of care for a client who is at 35wks of gestation and is experiencing
mild vaginal bleeding due to placenta previa. Which of the following interventions should the
nurse include?
Answer: Initiate continuous monitoring of the FHR.
Rationale:
Initiate continuous monitoring of the FHR and uterine activity using an external fetal monitor.
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the following
statements should the charge nurse make?
Answer: A chancre lesion appears within 90 day after infection during the primary stage.
Rationale:
The charge nurse should identify that a chancre is the primary lesion that occurs during a syphilis
infection. This lesion appears within 90 days of exposure to the infection and begins as a painless
papule, which then erodes into an ulcer.
A nurse is assessing a newborn who was born 15min ago and has an axillary temperature of
36.1°C (97°F). Which of the following actions should the nurse take?
Answer: Place the newborn skin to skin on the mother's chest.
Rationale:
Expected reference range is 36.5-37.5°C (97.7-99.5°F) for a newborn. This temperature indicates
hypothermia. Hypothermia can lead to cold stress, causing tachypnea, decreased pulmonary
perfusion, and hypoglycemia.
A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due
to a postpartum hemorrhage. Which of the following findings is the best indication of adequate
perfusion and oxygenation?
Answer: Urinary output.
Rationale:
Greatest risk for the client is coma and cardiac arrest if adequate perfusion and oxygenation are
not achieved. The nurse should identify that a urinary output of at least 30 mL/hr. is the best

indication of adequate perfusion and oxygenation. The nurse should insert an indwelling urinary
catheter in a client who is experiencing manifestations of hypovolemic shock.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the
following results should the nurse report to the provider?
Answer: Hct 31%
Rationale:
Below the minimal expected value of greater than 33% during pregnancy. The nurse should
report this finding to the provider as it is an indication of anemia.
A nurse is monitoring the laboratory results for a client who has preeclampsia with severe
features. Which of the following results should the nurse expect?
Answer: Increased BUN.
Rationale:
Preeclampsia with severe features to exhibit an increase in BUN, or blood urea nitrogen. The
increase is caused by a decreased glomerular filtration rate, secondary to impaired renal
perfusion.
A nurse is preparing to obtain a blood specimen from a newborn via a heel stick. Which of the
following actions should the nurse take?
Answer: Warm the newborn's heel for 10mins prior to the puncture.
Rationale:
Warm heel for 5-10mins prior to puncture. Warming the heel causes vasodilation which enhances
blood flow to the puncture site.
A nurse is reviewing the laboratory report of a client who is at 31wks of gestation and has
gestation hypertension. Which of the following laboratory results should the nurse report to the
provider?
Answer: Platelet count 99,000/mm3.
Rationale:

A platelet count of 99,000/mm3, or thrombocytopenia, is an indication of HELLP syndrome, a
serious complication of gestational HTN.
A nurse is reviewing the laboratory report of a term newborn who is 24hrs old. Which of the
following laboratory results should the nurse report to the provider?
Answer: Glucose 35 mg/dL.
Rationale:
Reference range is 40-45 mg/dL for a newborn who is 24hrs old.
A nurse is assessing a newborn who was born 15mins ago. Which of the following actions
should the nurse take?
Answer: Count the respiratory rate for 60 seconds.
Rationale:
Newborn often have an irregular respiratory rate. Short periods of apnea, and shallow
respirations are expected findings for a newborn. The nurse should also assess for symmetry of
chest and abdominal movements during inhalation and exhalation.
A nurse is assessing a client who has genital herpes. Which of the following findings should the
nurse expect?
Answer: Ulcerated lesions on the labia.
Rationale:
The nurse should identify that ulcerated lesions on the labia are an expected findings for a client
who has genital herpes simplex virus. Other manifestations may include lymphadenopathy,
itching, and dysuria.

Document Details

  • Subject: Nursing
  • Exam Authority: ATI
  • Semester/Year: 2023

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