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ATI Maternal Newborn Proctored Exam 2023 (Detail Solutions and Resource for the test) A++
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ATI Maternal Newborn Proctored Exam2023
(Detail Solutions and Resource for the
test)
1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach
her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia
serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum
hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a bright red, topinkish
brown,to creamy white.
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the
contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late
decelerations are suspected and the nurse notifies the physician. Which is the rationale for this
action?
Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late
decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal
contractions.
, Correct: Late decelerations are associated with uteroplacental insufficiency and are a signof
fetal hypoxia. Repeated late decelerations indicate fetal distress.
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal headMaternal
contractions are not adequate enough to deliver the fetus
The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a client who is scheduled to have
an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are postoperative
interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client
regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high,
because information would probably not be retained. In an emergency, there is time only for
essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of theclient
andthe family will be high. Inserting an indwelling catheter helps to keep thebladder empty and
free from injury when the incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are
important if the client is to receive general anesthesia, but the anesthesiologist will be listening to
breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother regarding care of the
breasts after discharge?
Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a result of
the breast milk formation. The primary way to relieve engorgement is by pumping or longer
nursing. Giving a bottle of formula will compound the problem because the baby will not be
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