ATI. MATERNAL-NEWBORN
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 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? .
The umbilical cord is wrapped tightly around the fetus' neck
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 should 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 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?
The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which
classification of drugs should the nurse anticipate administering?
Tocolytics
Anticonvulsants
Glucocorticoids
Anti-infective
6. Which of the following are probable signs, strongly indicating
pregnancy?
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
, 7. Two hours after delivery the nurse assesses the client and documents
that the fundus is soft, boggy, above the level of the umbilicus, and
displaced to the right side. The nurse encourages the client to void.
Which is the rationale for this nursing action?
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing
dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Ventrogluteal
Vastus lateralis
Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the
client voids 2,000 mL of urine. How should the nurse interpret this
finding?
High output renal failure
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot
maintain control of her blood sugar by diet alone, which medication will
she receive?
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 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? .
The umbilical cord is wrapped tightly around the fetus' neck
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 should 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 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?
The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which
classification of drugs should the nurse anticipate administering?
Tocolytics
Anticonvulsants
Glucocorticoids
Anti-infective
6. Which of the following are probable signs, strongly indicating
pregnancy?
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
, 7. Two hours after delivery the nurse assesses the client and documents
that the fundus is soft, boggy, above the level of the umbilicus, and
displaced to the right side. The nurse encourages the client to void.
Which is the rationale for this nursing action?
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing
dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Ventrogluteal
Vastus lateralis
Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the
client voids 2,000 mL of urine. How should the nurse interpret this
finding?
High output renal failure
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot
maintain control of her blood sugar by diet alone, which medication will
she receive?
