Maternal Newborn ATI Practice Questions with complete solutions

Maternal Newborn ATI Practice Questions with complete solutions A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching? It prevents the formation of Rh antibodies in mothers who are Rh negative A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect? Weakened uterine contractions A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? "I will use only nonprescription medications while pregnant" A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? Document the findings and continue to monitor the client. A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching? "I should apply hot packs to my breasts during feeding." A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? The client requires a rubella immunization following delivery. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? Shortly after giving birth A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? Turn the client onto her side A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching? "This test requires the presence of amniotic fluid." A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients has a contraindication for receiving oral contraceptives? A 38-year-old client who reports smoking one pack of cigarettes every day A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? "What part of the exam makes you most nervous?" A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? Urinary output 40mL in 2 hr A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client? Empty her bladder immediately prior to the procedure. A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? Offer the client a snack of orange juice and crackers. A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.) - Fetal breathing - Fetal motion - Amniotic fluid A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.) - take them for a ride in the car - carry them in a front or back pack - swaddle them in a receiving blanket A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates an understanding of circumcision care? (Select all that apply.) -"I'll expect the plastic ring to fall off by itself within a week" - "I'll call the doctor if I see any bleeding" - "I'll make sure his diaper is loose in the front" A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? Observe for crowning. A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? "This will occur between the fourth and fifth months of pregnancy." A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? "I'll eat more protein at each meal." A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? "We can time your pain medication so that you have an hour or two before the next feeding." A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? Place the client in a lateral position A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? Have the client ambulate. A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant? 8... Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8. A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse? The mother applies lotion to the newborn's skin A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? Changes in the cervix A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority? BP 80/56 mm Hg A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? "I should remove extra blankets from my baby's crib." A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet? Peanut butter A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? Dyspnea A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take? Apply perineal pressure to the emerging fetal head. A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? Apply an external fetal monitor. A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score. The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb. A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next? Massage the client's fundus to promote contractions. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? Position the client with one hip elevated. A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? A client who is experiencing preterm labor at 26 weeks of gestation