ati maternal newborn assessment exam test for nursing students
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ATI MATERNAL NEWBORN
ASESSMENT TEST
A nurse on the postpartum unit is caring for a pt. following a cesarean birth.
Which of the following assessments is the nurse's priority?
a. parent-child attachment
b. amount of lochia
c. patency of the IV catheter
d. quality and quantity of urine
b. amount of lochia
when using the ABCs approach to client care, the nurse should place the priority in the
immediate postpartum period on assessing the amount of postpartum lochia. the
greatest risk to the client is bleeding and postpartum hemorrhage.
a nurse is caring for a client who is in labor and whose fetus is in the right
occiput posterior position. the client is dilated to 8cm and reports back pain.
which of the following actions should the nurse take?
a. apply sacral counter pressure
b. perform trancutaneous electrical nerve stimulation (TENS)
c. initiate slow-paced breathing
d. assist with biofeedback
a. apply sacral counter pressure
the nurse should apply sacral counter pressure to assist in relieving back labor pain
related to fetal posterior position
b. the nurse should perform TENS during the first stage of labor.
c. the nurse should transition a client to pattern-paced breathing during this stage of
labor.
d. The nurse should teach the client about biofeedback during the prenatal period for it
to be effective during labor.
,a nurse is demonstrating to a client how to bathe her newborn. in which order
should the nurse perform the following actions
a. wipe the newborn's eyes from inner canthus outward
b. wash the newborn's legs and feet
c. wash the newborn's neck by lifting the newborn's chin
d. cleanse the skin around the newborn's umbilical stump
e. clean the newborn's diaper area
a. wipe the newborn's eyes from inner canthus outward
c. wash the newborn's neck by lifting the newborn's chin
d. cleanse the skin around the newborn's umbilical stump
b. wash the newborn's legs and feet
e. clean the newborn's diaper area
The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to
dirty, approach.
a nurse is caring for a client and her partner who have experienced a fetal death.
which of the following actions should the nurse take?
a. take photos of the newborn to give to the parents
b. tell the parents that they can consider organ donation
c. encourage the parents to avoid allowing older children to visit them in the
hospital
d. explain to the parents the need to name the newborn
a. take photos of the newborn to give to the parents
the nurse should create a memory box that includes mementos of the newborn (ex:
photos, ID bands, newborn hat and blanket)
b. Organ donation can be considered if a newborn is delivered alive.
c. The nurse should encourage the client to allow older children to come to the hospital
as a beneficial part of the grieving process.
,d. The nurse should explain to the client that naming the baby can be helpful during the
grieving process, but it is not a requirement.
a nurse is caring for a client who is 36 weeks gestation and has a positive
contraction stress test. the nurse should plan to prepare the clients for which of
the following diagnostic tests?
a. biophysical profile
b. amniocentesis
c. cordocentesis
d. Kleihauer- Burke test
a. biophysical profile
a positive contraction stress test indicate further evaluation of the fetus is necessary. a
biophysical profile will provide further evaluation with real-time ultrasound
b. An amniocentesis is used to determine lung maturity, detect congenital anomalies,
and diagnose fetal hemolytic disease.
c. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of
isoimmune hemolytic anemia.
d. The Kleihauer-Betke test is used to determine the amount of fetal blood in the
maternal circulation when there is a risk of Rh-isoimmunization.
a nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. which of the following laboratory results should the nurse report to
the provider?
a. hct 39%
b. serum albumin 4.5 g/dL
c. WBC 9,000/mm3
d. platelets 50,000/mm3
d. platelets 50,000/mm3
a platelet count of 50,000/mm3 is below the expected reference range, which can
indicate disseminated intravascular coagulation. the nurse should report this result to
the provider
a. An Hct of 39% is within the expected reference range and is not indicative of a
postpartum complication.
, b. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding
is consistent with mild preeclampsia and does not indicate a worsening of the condition.
c. A WBC of 9,000/mm3 is within the expected reference range.
a nurse is assessing a newborn who was born at 26 weeks gestation using the
Ballard score. which of the following findings should the nurse expect?
a. minimal arm recoil
b. popliteal angle of 90
c. creases over the entire foot sole
d. raised areolas with 3-4mm buds
a. minimal arm recoil
the nurse should expect a newborn that was born at 26 weeks to have decreased
muscular tone or minimal arm recoil
b. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational
age after 26 weeks.
c. Creases over the entire sole of a newborn's foot are an indicator of physical maturity
with increasing gestational age after 26 weeks.
d. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with
increasing gestational age after 26 weeks.
a nurse is assessing a newborn following a circumcision. which of the following
findings should the nurse identify as an early indication that the newborn is
experiencing pain?
a. decrease heart rate
b. chin quivering
c. pinpoint pupils
d. slowed respirations
b. chin quivering
behavioral responses to a newborn's pain include facial expressions (ex: chin quivering,
grimacing, furrowing of brow)
a. The heart rate will increase when a newborn is experiencing pain.
c. When experiencing pain, a newborn's pupils typically dilate.
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