ATI CAPSTONE MATERNAL NEWBORN
ASSESSMENT Questions and Answers
() (Verified Answers)
1. A nurse in a provider's office is planning to administer immunizations to an
11-year-old child who is up to date with current recommendations. Which of the
following immunizations should the nurse plan to administer?
A. Hepatitis B (Hep B)
B. Measles, mumps, rubella (MMR)
C. Tetanus, diphtheria, and pertussis (Tdap)
D. Pneumococcal (PCV)
Answer: C. Tetanus, diphtheria, and pertussis (Tdap)
2. A nurse in an antepartum clinic is reinforcing teaching with a pregnant client about
breastfeeding. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I should start trying to breastfeed within an hour of having my baby."
B. "I should give my baby formula between feedings if he loses 5 percent of his birth
weight."
C. "I should let my baby nurse for 10 minutes from each breast when he is hungry."
D. "I should offer my baby a pacifier after breastfeeding him if he is fussy."
Answer: A. "I should start trying to breastfeed within an hour of having my baby."
3. A nurse in an urgent care clinic is contributing to the plan of care for a child who
has suspected epiglottitis. Which of the following interventions should the nurse plan
to include?
A. Initiate contact precautions
B. Monitor pulse oximetry
C. Obtain a throat culture
D. Administer epinephrine IM
Answer: B. Monitor pulse oximetry
4. A nurse is assisting in the admission of a client who had recently given birth and is
presenting to the emergency department with acute opioid toxicity. Which of the
following findings should the nurse expect?
,A. Hypothermia
B. Hypertension
C. Diaphoresis
D. Mydriasis
Answer: A. Hypothermia
5. A nurse is assisting in the care of a child who is receiving IV cefuroxime when the
child begins to have difficulty breathing. Which of the following actions should the
nurse take first?
A. Obtain vital signs
B. Stop the IV infusion
C. Administer epinephrine IM
D. Monitor intake and output
Answer: B. Stop the IV infusion
6. A nurse is assisting with initial newborn data collection immediately following
delivery. The nurse should identify that which of the following findings requires
further evaluation?
A. Substernal retractions
B. Mongolian spots
C. Positive Babinski reflex
D. Erythema toxicum
Answer: A. Substernal retractions
7. A nurse is assisting with the care of a client who is at 36 weeks of gestation and
experienced premature rupture of membranes. Which of the following actions should
the nurse take?
A. Administer glucocorticoids
B. Monitor the client's temperature
C. Give calcium gluconate
D. Prepare the client for an amniocentesis
Answer: B. Monitor the client's temperature
8. A nurse is assisting with the care of a client who is experiencing a postpartum
hemorrhage. Which of the following actions should the nurse take? (Select all that
apply.)
, A. Firmly massage the fundus
B. Administer oxygen via a nonrebreather face mask
C. Ensure the client has IV access
D. Prepare the client for an amnioinfusion
E. Give the client Rh(D) immune globulin
Answer: A, B, C
9. A nurse is assisting with the care of a client who is receiving epidural anesthesia
for pain management during labor. Which of the following actions should the nurse
take?
A. Remind the client to void every 4 hr
B. Encourage the client to alternate from side to side every 2 hr
C. Raise the four side rails on the client's bed
D. Monitor the client's blood pressure
Answer: D. Monitor the client's blood pressure
10. A nurse is assisting with the care of an adolescent who has a partial-thickness
burn. When observing the site of the burn, which of the following clinical
manifestations should the nurse expect?
A. Brown in color
B. Leathery appearance
C. Visible ligaments
D. Blister formation
Answer: D. Blister formation
11. A nurse is caring for a 9-year-old client who is immediately postoperative. The
client is nonverbal and has both cognitive and developmental delays. Which of the
following pain scales should the nurse use to evaluate the client's pain?
A. FACES scale
B. Numerical scale
C. FLACC pain assessment scale
D. Visual analog scale
Answer: C. FLACC pain assessment scale
ASSESSMENT Questions and Answers
() (Verified Answers)
1. A nurse in a provider's office is planning to administer immunizations to an
11-year-old child who is up to date with current recommendations. Which of the
following immunizations should the nurse plan to administer?
A. Hepatitis B (Hep B)
B. Measles, mumps, rubella (MMR)
C. Tetanus, diphtheria, and pertussis (Tdap)
D. Pneumococcal (PCV)
Answer: C. Tetanus, diphtheria, and pertussis (Tdap)
2. A nurse in an antepartum clinic is reinforcing teaching with a pregnant client about
breastfeeding. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I should start trying to breastfeed within an hour of having my baby."
B. "I should give my baby formula between feedings if he loses 5 percent of his birth
weight."
C. "I should let my baby nurse for 10 minutes from each breast when he is hungry."
D. "I should offer my baby a pacifier after breastfeeding him if he is fussy."
Answer: A. "I should start trying to breastfeed within an hour of having my baby."
3. A nurse in an urgent care clinic is contributing to the plan of care for a child who
has suspected epiglottitis. Which of the following interventions should the nurse plan
to include?
A. Initiate contact precautions
B. Monitor pulse oximetry
C. Obtain a throat culture
D. Administer epinephrine IM
Answer: B. Monitor pulse oximetry
4. A nurse is assisting in the admission of a client who had recently given birth and is
presenting to the emergency department with acute opioid toxicity. Which of the
following findings should the nurse expect?
,A. Hypothermia
B. Hypertension
C. Diaphoresis
D. Mydriasis
Answer: A. Hypothermia
5. A nurse is assisting in the care of a child who is receiving IV cefuroxime when the
child begins to have difficulty breathing. Which of the following actions should the
nurse take first?
A. Obtain vital signs
B. Stop the IV infusion
C. Administer epinephrine IM
D. Monitor intake and output
Answer: B. Stop the IV infusion
6. A nurse is assisting with initial newborn data collection immediately following
delivery. The nurse should identify that which of the following findings requires
further evaluation?
A. Substernal retractions
B. Mongolian spots
C. Positive Babinski reflex
D. Erythema toxicum
Answer: A. Substernal retractions
7. A nurse is assisting with the care of a client who is at 36 weeks of gestation and
experienced premature rupture of membranes. Which of the following actions should
the nurse take?
A. Administer glucocorticoids
B. Monitor the client's temperature
C. Give calcium gluconate
D. Prepare the client for an amniocentesis
Answer: B. Monitor the client's temperature
8. A nurse is assisting with the care of a client who is experiencing a postpartum
hemorrhage. Which of the following actions should the nurse take? (Select all that
apply.)
, A. Firmly massage the fundus
B. Administer oxygen via a nonrebreather face mask
C. Ensure the client has IV access
D. Prepare the client for an amnioinfusion
E. Give the client Rh(D) immune globulin
Answer: A, B, C
9. A nurse is assisting with the care of a client who is receiving epidural anesthesia
for pain management during labor. Which of the following actions should the nurse
take?
A. Remind the client to void every 4 hr
B. Encourage the client to alternate from side to side every 2 hr
C. Raise the four side rails on the client's bed
D. Monitor the client's blood pressure
Answer: D. Monitor the client's blood pressure
10. A nurse is assisting with the care of an adolescent who has a partial-thickness
burn. When observing the site of the burn, which of the following clinical
manifestations should the nurse expect?
A. Brown in color
B. Leathery appearance
C. Visible ligaments
D. Blister formation
Answer: D. Blister formation
11. A nurse is caring for a 9-year-old client who is immediately postoperative. The
client is nonverbal and has both cognitive and developmental delays. Which of the
following pain scales should the nurse use to evaluate the client's pain?
A. FACES scale
B. Numerical scale
C. FLACC pain assessment scale
D. Visual analog scale
Answer: C. FLACC pain assessment scale
