ATI RN MATERNAL NEWBORN PROCTORED 2023
RETAKE EXAM WITH NGN VERSION 3 QNS & ANS
(VERIFIED REVISED FULL EXAM)
1) A nurse is assessing newborn following forceps assisted birth. Which of the
following clinical manifestations should the nurse identify as a complication of
the birth method?
A. Hypoglycemia
B. Polycythemia
C. Facial Palsy
D. Bronchopulmonary dysplasia
Answer: C
2) Which of the following statements by client indicates an understanding of the
teaching?
A. "The medication could cause me to experience heart palpitations"
B. "This medication could cause me to experience blurred vision"
C. "This medication could cause me to experience ringing in my ears"
D. "This medication could cause me to experience frequent ..."
Answer: A
3) A nurse is caring for a client who has hyperemesis gravidarum. Which of the
following laboratory tests should the nurse anticipate?
A. Urine Ketones
B. Rapid plasma regains
C. Prothrombin time
D. Urine culture
Answer: A
4) A nurse is caring for a client who is in labor and requests nonpharmacological
pain management. Which of the following nursing actions promotes client
comfort? (SATA.
A. Assisting the client into squatting position
B. Having the client lie in a supine position
C. Applying fundal pressure during contractions
D. Encouraging the client to void every 6 hr
Answer: A, D
5) A nurse caring for a client who is at 20 weeks of gestation and has
trichomoniasis. Which of the following findings should the nurse expect?
A. Thick, White Vaginal Discharge
B. Urinary Frequency
C. Vulva Lesions
D. Malodorous Discharge
Answer: D
6) A nurse is caring for a client who is 14 weeks of gestation. At which the
following locations should the nurse place the Doppler device when assessing
the fetal heart rate?
A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
B. Left Upper Abdomen
C. Two fingerbreadths above the umbilicus
D. Lateral at the Xiphoid Process
Answer: A
7) 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?
A. Urine protein contraction 200mg/24 hours
B. Creatine 0.8
C. Hemoglobin 14.8
D. Platelet 60,000
Answer: D
8) A nurse is teaching about clomiphene citrate to a client who is experiencing
infertility. Which of the following adverse effects should the nurse include?
A. Tinnitus
B. Urinary Frequency
C. Breast Tenderness
D. Chills
Answer: C (vision disturbances).
9) A nurse is assessing a newborn upon admission to the nursery. Which of the
following should the nurse expect?
A. Bulging fontanelles
B. Nasal flaring
C. Length from head to heel of 40cm
D. Chest circumference 2c (smaller than the head circumference
Answer: D
10) A nurse is planning care for a newborn who has necrotizing abstinence
syndrome. Which of the following interventions should the nurse include in the
plan of care?
A. Increase the newborn visual stimulation
B. Weigh the newborn everyday
C. Discourage parental interaction after a social evaluation
D. Swaddle the newborn in a flexed position
Answer: D
11) A nurse is caring for a newborn who his 6 hours old had has a bedside
glucometer reading of 65mg/dl. The newborns mother has type 2 diabetes
mellitus. Which of the following actions should the nurse take.
A. obtain a blood sampling for a serum glucose level.
B. Feed the newborn immediately
C. Administer 50ml of dextrose
D. Reassess the blood glucose reading prior to the next feeding
Answer: D
12) A nurse is providing teaching to a client about exercise safety during
pregnancy. Which of the folioing statements by the client indicates an
understanding of the teaching (SATA.?
A. I will limit my time in the hot tub to 30 miniutes after exercise
B. I should consume three 8 ounce glasses of water after I exercise
C. I will check my heart rate every 15 minutes during
D. I should limit exercise sessions to 30 minutes when the weather is humid
E. I should rest by lying on my side for 10 minutes following exercise.
Answer: B, D, E
13) A charge nurse is teaching a group of staff nurses about fetal monitoring
during labor. Which of the following findings should the charge nurse instruct
the staff members to report to the provider?
A. Contractions duration 95 seconds to 100 seconds
B. Contraction frequency 2-3 minutes
C. Absent early decelerations of fetal heart rate
Answer: C
14) A nurse in a woman's health clinic is obtaining a health history from a client.
Which of the following findings should the nurse identify as increasing the
client's risk for developing pelvic inflammatory disease (PID.?
A. Recurrent Cystitis
B. Frequent Alcohol Use
C. Use of Oral Contraceptives
D. Chlamydia Infection
Answer: D
15) A nurse is teaching a prenatal class about immunizations that newborns
receive following birth. Which of the following immunizations should the nurse
include in the teaching?
A. Hepatitis B
B. Rotavirus
C. Pneumococcal
D. Varicella
Answer: A
16) A nurse is providing nutritional guidance to a client who is pregnant and
follows a vegan diet. The client asks the nurse which foods she should eat to
ensure adequate calcium intake. The nurse should instruct the client that which
of the following foods has the highest amount of calcium?
A. ½ cup cubed avocado
B. 1 large banana
C. 1 medium potato
D. 1 cup cooked broccoli
Answer: D
17) A nurse in a provider's office is assessing a client at her first antepartum
visit. The client states that the first day of her last menstrual period was March 8.
Answer: December 15
18) A nurse is caring for a client who is in the second stage of labor. Which of
the following manifestations should the nurse expect?
A. The client expels the placenta
B. The client experiences gradual dilation of the cervix
C. The client begins have regular contractions.
D. The client delivers the newborn
Answer: D
19) A nurse is assessing a client who is at 37 weeks of gestation. Which of the
following statements by the client requires immediate intervention by the nurse?
A. "It burns when I urinate
B. "My feet are really swollen today".
Answer: A
20) A nurse is providing discharge teaching to a new parent about car seat safety.
Which of the following statements by the parent indicates an understanding of
the teaching?
A. "I should position my baby's car seat at a 45 degree angle in the car."
B. "I should place the car seat rear facing until my baby is 12 months old."
C. "I should place the harness snugly in a slot above my baby's sholders."
D. "I should position the retainer clip at the top of my baby's abdomen.
Answer: B
21) A nurse on an antepartum unit is reviewing the medical records for four
clients. Which of the following clients should the nurse assess first?
A. A client who has diabetes mellitus and an HbA1c of 5.8%
B. A client who has preeclampsia and a creatinine level of 1.1 mg/ Dl
C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
D. A client who has placenta previa and a hematocrit of 36%
Answer: C
22) A nurse on the postpartum unit is caring for four clients. For which of the
following clients should the nurse notify the provider?
A. A client who has a urinary output of 300 ml in 8 hr
B. A client who reports abdominal cramping during breastfeeding
C. A client who is receiving magnesium sulfate and has absent deep tendon
reflexes
D. A client who reports lochia rhubra requiring changing perineal pads every 3 h
Answer: C
23) A nurse is caring for a client who has active genital herpes simplex virus
type 2. Which of the following medications should the nurse plan to administer?
A. Metronidazole
B. Penicillin
C. Acyclovir
D. Gentamicin
Answer: C
24) A nurse is caring for a client following an amniocentesis. The nurse should
observe the client for which of the following complications?
A. Hyperemesis
B. Proteinuria
C. Hypoxia
D. Hemorrhage
Answer: D
25) 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?
A. Increase the infusion rate every 30 to 60 min.
B. Maintain the client in a supine position.
C. Titrate the infusion rate by 4 milliunits/min.
D. Limit IV intake to 4 L per 24 hr
Answer: A
26) A nurse is caring for a 2-day-old newborn who was born at 35 weeks of
gestation. Which of the following actions should the nurse the nurse takes?
(Click on the "Exhibit" Button for additional information about the newborn.
There are three tabs that contain separate categories of date.)
A. Administer nitric oxide inhalation therapy to the newborn
B. Insert an orogastric decompression tube with low wall suction.
C. Provide the newborn with an iron-rich formula containing vitamin B12 every
2 hr.
D. Measure the abdominal circumference at the level of the newborn's umbilicus
every 2 hr
Answer: D
27) A nurse is caring for a client who is receiving oxytocin for induction of labor
and notes late decelerations of the fetal heart rate on the monitor Tracing. Which
of the following action should the nurse take?
A. Decrease maintenance IV solution infusion rate.
B. Place the client in lateral position.
C. Administer misoprostol 25 mcg vaginally
D. Administer oxygen via face mask at 2 L/min
Answer: B
28) A nurse is planning care for a client who is pregnant and has HIV. Which of
the following actions should the nurse include in the plan of care?
A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of
gestation.
B. Use a fetal scalp electrode during labor and delivery.
C. Administer a pneumococcal immunization to the newborn within 4 hr
following birth.
D. Bathe the newborn before initiating skin-to-skin contact
Answer: D
29) A nurse is preparing to administer methylergonovine 0.2 mg orally to a client
who is 2 hr postpartum and has a boggy uterus. For which of the following
assessment findings should the nurse withhold the medication?
A. Blood pressure 142/92 mm Hg
B. Urine output 100 mL in hr
C. Pulse 58/min
D. Respiratory rate 14/min
Answer: A
30) A nurse is reviewing laboratory results for client who is pregnant. The Nurse
should expect which of the following laboratory values to increase?
A. RBC count
B. Bilirubin
C. Fasting blood glucose
D. Bun
Answer: A or C
31) A nurse is caring for four clients. For which of the following clients should
the nurse auscultate the fetal heart rate during the prenatal visit?
A. A client who has an ultrasound that confirms a molar pregnancy
B. A client who has a crown-rump length of 7 weeks gestation
C. A client who has a positive urine pregnancy test 1 week after missed menses
D. A client who has felt quickening for the first time
Answer: D
32) A nurse is planning care for a full-term newborn who is receiving
phototherapy. Which of the following actions should the nurse include in the
plan of care?
A. Dress the newborn in lightweight clothing.
B. Avoid using lotion or ointment on the newborn skin.
C. Keep the newborn supine throughout treatment
D. Measure the newborn's temperature every 8hr
Answer: B
33) A nurse is receiving laboratory results for a term newborn who is 24 hr old.
Which of the following results require intervention by the nurse?
A. WBC count 10,000/mm3
B. Platelets 180,000/mm3
C. Hemoglobin 20g/dL
D. Glucose 20 mg/d
Answer: D
34) A nurse is assessing a client following an amniocentesis. Which of the
following findings should the nurse recognize as complications? (select all that
apply).
A. Amnionitis
B. Urinary tract infection
C. Polyhydramnios
D. Leakage of amniotic fluid
E. Preterm labor
Answer: A, D, E
35) A nurse on a labor and delivery unit is receiving infection control standards
with a newly licensed nurse. The nurse should instruct the newly licensed nurse
to don gloves for which of the following procedures?
A. Assisting a mother with breastfeeding
B. Performing a newborn's initial bath
C. Administering the measles, mumps, rubella vaccine
D. Performing umbilical cord care
Answer: D
36) A nurse is providing teaching to a client who has mild preeclampsia and will
be caring for herself at home during the last 2 months of pregnancy. This of the
following statements by the client indicates an understanding of the teaching.
A. "I will count baby's lacks every other day.
B. "I will alternate the arm use to check my blood pressure.
C. I will consume 50 grams of protein daily
Answer: B
37) A nurse is caring for four newborns. Which of the following newborns
should the nurse assess first?
A. newborn who has nasal flaring
B. newborn who has subconjunctival hemorrhage of the left eye
C. A newborn who has overlapping suture lines
D. A newborn who has not rust-stained urine
Answer: A
38) A nurse is reviewing the electronic medical record of a postpartum client.
The nurse should identify that which of the following factors paces the client at
risk for infection.
A. Meconium
B. placenta previa
C. Midline episiotomy
D. Gestational hypertension
Answer: A
39) A nurse is caring for a client who is 4hr postpartum and is experiencing
hypovolemic shock. Which of the following actions should the nurse take?
A. Administer indomethacin
B. Insert a second using a 22-gauge IV catheter,
C. Insert an indwelling urinary catheter.
D. Administer oxygen at 4L/min via nasal cannula.
Answer: C
40) A nurse is teaching a client who is 28 weeks of gestation and not up-to date
on current immunization. Which of the following immunizations should the
nurse inform the client to anticipate receiving following birth.
A. Pneumococcal
B. Hepatitis
C. Human papillomavirus
D. Rubella
Answer: D
41) A nurse is caring for a newborn who is 24 hr old. Which of the following
Laboratory findings should the nurse report to the provider?
A. Hgb 20 g/dL
B. Bilirubin 2mg/dL
C. Platelets 200 .000/mm3
D. WBC count 32.000/mm3
Answer: D
42) A nurse is caring for newborn who is 1 hr old and has a respiratory rate of
50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F).
Which of the following actions should the nurse take?
A. Give the newborn a warm bath.
B. Apply a cap to the newborn head.
C. Reposition the newborn.
D. Obtain an oxygen saturation leve
Answer: B
43) A nurse is planning care for a newborn who is scheduled to start
phototherapy using a lamp. Which of the following actions should the nurse
include in the plan?
A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
B. Give the newborn 1oz of glucose water every 4 hrs
C. Ensure the newborn eyes are closed beneath the shield.
D. Dress the newborn in a thin layer of clothing during therapy
Answer: C
44) A nurse is providing teaching to a client who is at 38 weeks of gestation and
has a prescription to receive misoprostol intravaginally. Which of the following
statement should the nurse make?
A. "you will need to stay in a side-lying position for 30 minutes after each dose."
B. "You will receive an IV infusion of oxytocin 1 hour after your last dose."
C. " You will receive a magnesium supplement immediately following therapy."
D. " You will need to have a full bladder before the therapy begins
Answer: A
45) A nurse is assessing a newborn who was born Postterm. Which of the
following findings should the nurse expect?
A. Nails extending over tips of fingers
B. Large deposits of subcutaneous fat
C. Pale, translucent skin
D. Thin covering of fine hair on shoulders and back
Answer: A
46) A nurse is planning to teach a group of clients who are about breastfeeding
after returning to work .Which of the following infection should the nurse
include in the teaching?
A. "Thawed breast milk can be refrigerated for up to 72 hours."
B. "Breast milk can be stored in a deep freezer for 12 months."
C. Breast milk can be stored at room temperature for up to 12 hours."
D. "Thawed breast milk that is unused can be refrozen."
Answer: B
47) A nurse is caring for an infant who has signs of neonatal abstinence
syndrome. Which of the following actions should the nurse take?
A. Provide a stimulating environment
B. Monitor blood glucose level every hr.
C. Initiate seizure precautions.
D. Place the infants on his back with legs extended
Answer: B
48) A nurse is reviewing signs of effective breathing with a client who is 5 days
postpartum. Which of the following information should the nurse include in the
teaching?
A. "You should feel a tugging sensation when the baby is sucking.
B. You should expect your baby to have two to three wet diapers in 24hour
period
C. "Your baby's urine should appear dark and concentrated"
D. "Your breast should stay firm after the baby breastfeeds"
Answer: A
49) A nurse is teaching a client who is at 41 weeks of gestation about a non
stress test. Which of the following information should the nurse include in the
teaching?
A. "This test will confirm fetal lung maturity ".
B. "This test will determine adequacy of placental perfusion".
C. "This test will detect fetal infection".
D. "This test will predict maternal readiness for labor"
Answer: B
50) A nurse on the labor and delivery unit is assessing four clients. Which of the
following clients is a candidate for an induction of labor with misoprostol?
A. client who has active genital herpes
B. A client who has gestational diabetes mellitus
C. A client who has a previous uterine incision
D. A client who has placenta previa
Answer: B
51) A nurse is monitoring a client who has preeclampsia and is receiving
magnesium sulfate by continuous IV infusion. Which of the following findings
should the nurse reports to the provider?
A. Blood pressure 148/94mm Hg
B. Respiratory rate 14mm
C. Urinary output 20 mL/hr
D. 2+deep tendon reflexes
Answer: C
52) A nurse is caring for a client who is in the transition phase of labor and
reports a pain level of 7 on a scale of 0 to 10. Which of the following actions
should the nurse take?
A. Instruct the client to use effleurage
B. Apply counter pressure to the client sacral.
C. Assist the client with patterned-paced breathing.
D. Teach the client the technique of biofeedback.
Answer: C
53) A nurse is caring for newborn immediately following birth and notes a large
amount of mucus in the newborn's mouth and nose. Identify the sequence the
nurse should follow when performing suction with a bulb syringe. (Move the
streps into the box on the placing them in the selected order of performance. Use
all the streps.)
A. Assess the newborn for reflex bradycardia.
B. Compress the bulb syringe
C. Place the bulb syringe in the newborn's mouth.
D. Use the bulb syringe to suction the newborn's nose.
Answer: A, B, C, D
54) A community health nurse is providing education on gestational diabetes
mellitus (GDM) to a group of clients who are pregnant when discussing risk
factors, which of the following ethnicities should the nurse identify as having
the lowest incidence of GDM?
A. Asian
B. Non-Hispanic White American
C. Hispanic
D. African American
Answer: B
55) A nurse is assessing a client who is at 37 weeks of gestation. Which of the
following statement by the client requires immediate intervention by the nurse?
A. "It burns when I urinate
B. "My feet are really swollen today".
C. "I didn't have lunch today, but I have breakfast this morning".
D. "I have been seeing spot this morning"
Answer: A
56) 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?
A. "Your stomach will empty rapidly"
B. "You should expect your uterus to double in size"
C. "You should anticipate nasal stuffiness."
D. "Your nipples will become lighter in color"
Answer: B
57) A nurse is teaching a prenatal class regarding false labor. Which of the
following information should the nurse include?
A. "your contraction will become more intense when walking"
B. "you will have dilation and effacement of the cervix"
C. “You will have bloody show"
D. "Your contraction will become temporally regular”
Answer: D
58) A nurse is caring for a client who is receiving an epidural block with an
opioid analgesic. The nurse should monitor for which of the following findings
as an adverse effect of the medication?
A. Hypnosis
B. Polyuria
C. Bilateral crackles
D. Hyperglycemia
Answer: C. Bilateral crackles
59) A nurse is caring for a client who is receiving prenatal care and is at her 24week appointment. Which of the following laboratory tests should the nurse
plans to conduct?
A. Group
B. strep culture 1-hr glucose tolerance test
C. Rubella titer
D. Blood type and Rh
Answer: B. strep culture 1-hr glucose tolerance test
60) A nurse is caring for a client who has bacterial vaginosis. Which of the
following medication should the nurse expect to administer?
A. Metronidale
B. Fluconazole
C. Acyclovir
Answer: A
61) A nurse is caring for a client who is experiencing sore nipples from
breastfeeding. Which of the following actions should the nurse take?
A. Place a snug dressing on the client's nipple when not breastfeeding.
B. Ensure the newborn's mouth is wide open before latching to the breast.
C. Encourage the client to limit the newborn's feeding to 10 min on each breast.
D. Instruct the client to begin the feeding with the nipple that is most tender Answer: B
62) A nurse is assessing a preterm newborn who is at 32 weeks of gestation.
Which of the following finding should the nurse expect?
A. Minimal arm recoil
B. Popliteal angle of less than 90
C. Creases over the entire sole
D. Sparse lanugo
Answer: A
63) A nurse on a labor and delivery unit is providing teaching to a client who
plans to use hypnosis to control labor pain. Which of the following information
should the nurse include?
A. Focusing on controlling body functions
B. "Synchronized breathing will be required during hypnosis"
C. "Hypnosis can be beneficial in you practiced it during the prenatal period"
D. "Hypnosis does not work for controlling pain associated with labor".
Answer: C. "Hypnosis can be beneficial in you practiced it during the prenatal
period"
64) Which of the following assessment findings in an infant should indicate to a
nurse that suctioning of the nasopharynx is needed?
A. The infant is beginning to cough
B. The newborns pulse oximetry is 91
C. The infant's respiratory rate is 32/min.
D. The infant's respiratory rate is irregular
Answer: A
65) A nurse is providing teaching to a postpartum client who has type 1 diabetes
and is breastfeeding her newborn. Which of the following instructions should
the nurse give to the client?
A. Take more insulin with each meal that you did prior to pre pregnancy
B. Maintain scheduled mealtimes for yourself
C. Check your blood glucose levels every 8 hours
D. Limit your carbohydrate intake to 30 grams per day
Answer: B
66) A nurse is assessing the reflexes of a term newborn. After placing the
newborn in a supine position, which of the following would the nurse use to
elicit the Moro reflex
A. Turn the newborn's head to one side
B. Make a loud noise above the newborn
C. Tap the newborns forehead with a finger
D. Touch the newborns cheek with a finger
Answer: B
67) A nurse is performing a nonstress test on a client who is at 35 weeks of
gestation and has diabetes. The test reveals no accelerations of the fetal heart
rate for 20 minutes. Which of the following actions should the nurse take?
A. Perform vibroacoustic stimulation
B. Collect a specimen for an indirect Coomb's test
C. Conduct a vaginal exam
D. Place the client in the Trendelenburg position
Answer: A
68) A nurse is caring for a client who is 1-day post-partum and breastfeeding her
newborn. The client reports sore nipples. Which of the following actions should
the nurse take?
A. Have the client limit the length of breastfeeding to 5 minutes per breast
B. Assess the newborns latch while breastfeeding
C. Offer supplemental formula between the newborn's feedings
D. Instruct the client to wait 4 hours between daytime feedings
Answer: B
69) A nurse is admitting a client who is in active labor and has had two prior
cesarean births. The nurse should identify that the client is at an increased risk
for which of the following complications?
A. Uterine rupture
B. Precipitous labor
C. Failure to progress
D. Abruptio placentae
Answer: D
70) A nurse is caring for a 2-day old newborn who was born at 35 weeks
gestation. Which of the following actions should the nurse take?
A. Measure the abdominal circumference at the level of the newborn's umbilicus
every 12 hours
B. Provide the newborn with an iron rich formula containing vitamin b12 every
12 hours
C. Administer nitric oxide inhalation therapy to the newborn
D. Insert an orogastric decompression tube with low suction
Answer: A
71) A nurse in a clinic is caring for a client who is in her second trimester of
pregnancy. The client expresses concerns about preparing her 2-year-old for a
new sibling.
A. Move your toddler to his new bed 2 months before the baby comes home
B. Avoid bringing your toddler to prenatal visits
C. Require scheduled interactions between the toddler and the baby
D. Let your toddler see you carry the baby into the home for the first time
Answer: C
72) 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?
A. Place newborn bassinets at least 3 feet apart
B. Maintain airborne precautions
C. Allow parents to enter the nursery if wearing a mask
D. Place the newborns foot on a sterile field during a heel stick
Answer: A
73) A nurse is caring for a client who is in active labor and reports sudden,
severe lower abdominal pain. The nurse observes a drop in the client's blood
pressure and notes cool skin and pallor. The fetal heart rate tracing shows
prolonged bradycardia. Which of the following complications should the nurse
expect?
A. Placenta Previa
B. Amniotic fluid embolism
C. Uterine rupture
D. Umbilical cord prolapse
Answer: C
74) A nurse is reviewing the medical record for a client who is receiving
treatment for gestational diabetes. Which of the following medications should
the nurse expect to administer?
A. Nifedipine
B. Chlorpromazine
C. Glyburide
D. Levothyroxine
Answer: C
75) 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?
A. Urine protein of 3+
B. Deep tendon reflexes of 2+
C. Hemoglobin 13
D. Blood glucose 110
Answer: A
76) A nurse is admitting a client who is at 38 weeks gestation following
spontaneous rupture of membranes. The nurse performs a vaginal examination
and palpates the umbilical cord. Which of the following actions should the nurse
take first?
A. Request that the provider insert an intrauterine pressure catheter
B. Initiate oxytocin via continuous IV infusion
C. Place the client in a left lateral position
D. Exert continuous upward pressure on the presenting part
Answer: D
77) A nurse is caring for a client who is in labor. Which of the following findings
should prompt the nurse to reassess the client?
A. An urge to have a bowel movement during contractions
B. Progressive sacral discomfort during contractions
C. A sense of excitement and warm, flushed skin
D. Intense contractions lasting 45 to 60 seconds
Answer: A
78) A nurse is assessing a client who is at 39 weeks of gestation and determines
that the fetus is in a left occipitoanterior position. On which of the following
sites should the nurse place the external fetal monitor to hear the point of
maximum impulse of the fetal heart rate?
A. LLQ
B. LUQ
C. RLQ
D. RUQ
Answer: A
79) A nurse is assessing a full-term newborn. Which of the following findings
should the nurse report to the provider?
A. Temperature 36.5 degrees C (97.7 degrees F)
B. Blood pressure 80/50 mm Hg
C. Respiratory rate 55/min
D. Heart rate 72/min
Answer: D
80) A nurse is performing an assessment for a newborn and notes breast tissue
that has a flat areola with no bud. The nurse should identify that this finding
indicates which of the following?
A. Decreased maternal hormones during pregnancy
B. Congenital anomaly
C. Preterm gestational age
D. Ambiguous secondary sex characteristics
Answer: C
81) A nurse is reviewing the medical records of a client who had a vaginal
delivery 3 hours ago. Which of the following findings place the client at risk for
post-partum hemorrhage? SATA
A. History of uterine atony
B. Vacuum assisted birth
C. Labor induction with oxytocin
D. Normal weight
E. History of HPV
Answer: A, C
82) A nurse is caring for a client who has maternal hypotension following the
placement of an epidural. Which of the following actions should the nurse take?
A. Position the client in a knee-chest position
B. Give terbutaline subcutaneously
C. Apply oxygen via nonrebreather face mask
D. Administer a bolus infusion of lactated Ringer's
Answer: D
83) A nurse is assisting the provider to administer dinoprostone insert to induce
labor. Which of the following actions should the nurse take?
A. Verify informed consent is obtained
B. Place the client in a semi-fowlers position
C. Instruct the client to avoid urinary elimination until after administration
D. Allow the medication to reach room temperature prior to administration
Answer: D
84) A nurse is performing an initial assessment of a newborn who was delivered
with a nuchal cord. Which of the following should the nurse expect?
A. Facial petechiae
B. Telangiectatic nevi
C. Erythema toxicum
D. Periauricular papilloma's
Answer: A
85) A nurse is caring for a client who is experiencing uterine atony immediately
following delivery. The client fails to respond to oxytocin. The nurse should
anticipate the use of which of the following medications?
A. Hydralazine
B. Methylergonovine
C. Terbutaline
D. Betamethasone
Answer: B
86) A nurse is caring for a client who has preeclampsia and is receiving
magnesium sulfate. Which of the following clinical findings should the nurse
instruct the client to report?
A. Increased respiratory rate
B. Increased fetal movement
C. Increased muscle weakness
D. Increased urine output
Answer: C
87) A nurse is teaching a newly hired nurse about Apgar scoring. Which of the
following statements indicate an understanding of the teaching?
A. The nurse should wait for the first Apgar score before initiating resuscitation
efforts
B. The nurse should identify that the newborn is in severe distress with an Apgar
score of 8
C. The nurse should measure the newborns muscle tone when assigning an
Apgar score
D. The nurse should determine the Apgar score at 2 and 7 minutes after birth
Answer: C
88) A nurse is caring for a client who has pregestational diabetes. Which of the
following findings should indicate to the nurse the client has hyperglycemia?
A. Dizziness
B. Increased urination
C. Sweating
D. Double vision
Answer: B
89) A nurse is providing teaching to a client about postpartum care. Which of the
following information should the nurse include?
A. Breasts will be firm and tender 3 to 5 days after delivery
B. Bleeding will remain bright red for the next 6 to 8 weeks
C. You don't need to use birth control if you are exclusively breastfeeding
D. You should begin performing Kegel exercises 6 to 7 weeks after delivery
Answer: A
90) A nurse is caring for a client who is at 30 weeks of gestations and receiving
magnesium sulfate for preeclampsia. The nurse should recognize which of the
following manifestations as an adverse reaction to the medication?
A. Hyperglycemia
B. Urine output 20 mL/hour
C. Hypertension
D. Respiratory rate 16/min
Answer: B
91) A nurse is caring for newborn who is 1 hour old and has a respiratory rate of
50/min, a heart rate of 130/minute, and an axillary temperature of 36.1 (97).
Which of the following actions should the nurse take?
A. Apply a cap to the newborns head
B. Obtain an oxygen saturation level
C. Reposition the newborn
D. Give the newborn a warm bath
Answer: A
92) A nurse is assessing a newborn whose mother had a primary
cytomegalovirus infection during pregnancy. The newborns acquired CMV trans
placentally. Which of the following findings should the nurse expect the
newborn to exhibit?
A. Urinary tract infection
B. Cataracts
C. Hearing loss
D. Macrosomia
Answer: C
93) A nurse is teaching a newly licensed nurse about the use of ultrasonography
in the first trimester. Which of the following statements by the newly licensed
nurse indicates an understanding of the teaching?
A. Ultrasound is used to determine gestational age in the first trimester
B. Ultrasound is used to perform biophysical profile in the first trimester
C. Ultrasound is used to observe for placental maturity in the first trimester
D. Ultrasound is used to detect IUGR in the first trimester
Answer: A
94) A nurse is reviewing the laboratory results of a client who is at 20 weeks of
gestation and has type 1 diabetes. Which of the following findings should the
nurse report to the provider?
A. BUN 25
B. HbA1c 6%
C. Hct 34%
D. Platelets 170,000
Answer: A
95) A nurse is reviewing the laboratory report for a client who is in active labor.
The client tested positive for group B strep. Which of the following medications
should the nurse plan to administer to the client
A. Ampicillin
B. Cefotetan
C. Doxycycline
D. Fluconazole
Answer: A
96) A nurse on an antepartum unit is receiving change of shift report for four
clients. Which of the following should the nurse assess first?
A. A client who is at 38 weeks gestation and is experiencing painful urination
B. A client who is at 12 weeks gestation and is experiencing nausea and
vomiting
C. A client who is at 34 weeks gestation and is experiencing epigastric pain and
headache
D. A client who is at 39 weeks gestation and is experiencing cramping and
spotting
Answer: C
97) A nurse is providing discharge teaching to a postpartum client about caring
for her 5-day-old male newborn at home. Which of the following statements
should the nurse make to the client?
A. Notify your baby's pediatrician if he urinates less than six times a day
B. Swaddle your baby tightly with his legs extended before laying him down to
sleep
C. Place triple antibiotic ointment on your baby's umbilical cord twice per day
D. Retract the foreskin to clean your baby's penis during each bath
Answer: A
98) 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.
A. Subconjunctival hemorrhage
B. Rust stained urine
C. Single palmar creases
D. Transient circumoral cyanosis
Answer: D
99) A nurse in a provider's office is caring for a 20-year-old client who is at 12
weeks gestation. The nurse should report which of the following findings to the
provider as an indication of an imminent spontaneous abortion?
A. Elevated hCG
B. Scant, bright red spotting
C. Cervical dilation
D. Slight abdominal cramps
Answer: B
