ATI MATERNAL NEWBORN PROCTORED EXAM VERSION 1 A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device? Menorrhagia A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include? You should use fluoride base tooth paste to prevent dental caries A nurse is assisting with the plan of care for a client who is pregnant and is Rh -negative. In which of the following situations should the nurse administer Rh(D) Immune Glob ulin? at 28 weeks gestattion A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? frequent stimulation A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? group b streptococcus B -hemolytic culture A nurse is assisting in the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? ensure the newborns eyes are closed applying the eye shield A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the nurse's priority? my heart feels as it is racing A nurse is assisting with caring for a client who is at 36 weeks of gestation and has pre -
eclampsia. Which of the following findings should the nurse identify as the priority? nonreactive stress test A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink w ith acrocyanosis. Which of the following actions should the nurse take? continue to routinely monitor the newborn A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the nurse include in the teaching as a nutrient for the client to increase the intake of while breastfeeding? calcium A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Nagele's rule, which of the following is the clie nt's expected date of birth (EDB)? April 15 A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take f irst? massage the fundus A nurse is reinforcing discharge instructions with a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? don't become pregnant for least a year A nurse is preparing a client who is pregnant for an ultrasound. Which of the following information is the most important for the nurse to collect? time of client last void A nurse is reinforcing teaching with a client about a nonstress test. Which of the f ollowing statements by the client indicates an understanding of the teaching? i should press the button when i feel the baby move A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions should the nurse t ake? initiate a latex free environment A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following information should the nurse include? you should have burst of 15 sucks or swallows at a time A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan? you and your partner need to take the medication and use a condom during intercourse until cultures are negative A nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre -eclampsia. Which of the following is a contraindication for use of this medication? active genital herpes A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? these feelings are comm on for expectant fathers in early pregnancy A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching? you will have a c -section at t he onset of labor A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a 12 - hour old who has hr70beats/min while sleeping A nurse is assisting with the care of a preterm newborn who is receiving ox ygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? retinopathy A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? i will warm the formula by placing it in a pan of hot water A nurse is collecting data for a newborn who is 12 hr old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? obtain a stat prescription fora bilirubin levels A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia? a newborn who is large for gestation age A nurse administers betame thasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When assisting with the plan of care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? decreased blood glucose A nurse is collecting data on a client who is at 8 weeks of gestation. Which of the following findings should the nurse report to the provider? small amount of brown vaginal discharge A nurse is caring for a client who is at 16 weeks of gestation and has severe iron -deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? use a 20 gauge needle using the z -tract method A nurse is caring fo r a client who is at 8 weeks of gestation with twins and is primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurs e make? these feelings are normal at the beginning of pregnancy A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? a weight gain of 25 -35 pounds is good A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? exaggerated reflexes A nurse is contributing to the plan of care for a client who plans to formula feed her newborn. Which of the following actions should the nurse include in the plan? have the client place ice packs on her breast 4 times per day A nurse is discussing diaphrag m use with a client. Which of the following statements by the client indicates an understanding of the teaching? i should replace my diaphragm every 2 years A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take? instruct the client about vena cava syndrome and ways to prevent it A nurse is c ollecting data on a newborn who was born at 43 weeks of gestation. Which of the following findings should the nurse expect? absent of vernix A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following fin dings is a risk factor for an ectopic pregnancy? pelvic inflammatory disease A nurse is preparing to elicit the fencing reflex from a newborn. Which of the following actions should the nurse take? turn the newborns head closely to one side A nurse is car ing for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide to the client? you should eat some cracker before rising from bed in the morning A nurse is collecting data from a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3° C (99.2° F), and pulse rate 52/min. Which of the following actions should the nurse take? ask client when was the last time they void (VERSION 2) 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? 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 fou r 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 contra ctions, 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? . The umbilical cord is wrapped tightly around the fetus' ne ck The fetal cord is being compressed due to rapid descent of the fetal head Maternal 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 sho uld be included for a client who is scheduled to have an emergency cesarean birth? Monitor oxygen saturation and administer pain medication. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and inser t an indwelling catheter .
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