ATI Maternal Newborn Proctored
Study Guide
A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to the
provider?
**Platelets 50,000/mm3**
- A platelet count of 50,000/mm3 is below the expected reference range, which
can indicate disseminated intravascular coagulation. The nurse should report this
result to the provider.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?
**Minimal arm recoil**
- The nurse should expect a newborn who was born at 26 weeks gestation to have
decreased muscular tone, or minimal arm recoil.
A nurse is assessing a newborn following circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
**Chin quivering**
- Behavioral responses to a newborn’s pain include facial expressions (ex: chin
quivering, grimacing, & furrowing of the brow).
A nurse is assessing the newborn of a client who took a selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the
nurse identify as an indication of withdrawal from an SSRI?
**Vomiting**
- Expected clinical manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, & vomiting. These usually last 2 days.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
**Remove all clothing from the newborn except the diaper.**
, - The nurse should remove all of the newborn’s clothing except the diaper while
under phototherapy. Maximum skin exposure to the ultraviolet light is needed to
break down the excess bilirubin.
A nurse is creating a plan of care for a client who is postpartum and adheres to
traditional Hispanic cultural beliefs. Which of the following cultural practices should the
nurse include in the plan of care?
**Protect the client’s head and feet from cold air.**
- Protecting the client’s head and feet from cold air should be included in the plan
of care because this is a traditional Hispanic practice during the postpartum
period. Hispanic practices also include delaying bathing for 14 days, bed rest for
3 days, and drinking warm beverages following delivery.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal
monitoring?
**Perform Leopold maneuvers.**
- The nurse should perform Leopold maneuvers to assess the position of the fetus
to best determine the optimal placement for the external fetal monitoring
transducer.
A nurse is caring for a client who is in active labor and has had no cervical change in
the last 4 hours. Which of the following statements should the nurse make?
**”Your provider will insert an intrauterine pressure catheter to monitor the
strength of your contractions.”**
- Insertion of an intrauterine pressure catheter is necessary to determine uterine
contraction intensity, which will identify whether or not the contractions are
adequate for the progression of labor.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic
shock. After notifying the provider, which of the following actions should the nurse take
next?
**Massage the client’s fundus.**
- The greatest risk to the client is hemorrhage. Therefore, the next action the nurse
should take is to massage the client’s fundus to expel clots and promote
contractions.
Study Guide
A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to the
provider?
**Platelets 50,000/mm3**
- A platelet count of 50,000/mm3 is below the expected reference range, which
can indicate disseminated intravascular coagulation. The nurse should report this
result to the provider.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?
**Minimal arm recoil**
- The nurse should expect a newborn who was born at 26 weeks gestation to have
decreased muscular tone, or minimal arm recoil.
A nurse is assessing a newborn following circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
**Chin quivering**
- Behavioral responses to a newborn’s pain include facial expressions (ex: chin
quivering, grimacing, & furrowing of the brow).
A nurse is assessing the newborn of a client who took a selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the
nurse identify as an indication of withdrawal from an SSRI?
**Vomiting**
- Expected clinical manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, & vomiting. These usually last 2 days.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
**Remove all clothing from the newborn except the diaper.**
, - The nurse should remove all of the newborn’s clothing except the diaper while
under phototherapy. Maximum skin exposure to the ultraviolet light is needed to
break down the excess bilirubin.
A nurse is creating a plan of care for a client who is postpartum and adheres to
traditional Hispanic cultural beliefs. Which of the following cultural practices should the
nurse include in the plan of care?
**Protect the client’s head and feet from cold air.**
- Protecting the client’s head and feet from cold air should be included in the plan
of care because this is a traditional Hispanic practice during the postpartum
period. Hispanic practices also include delaying bathing for 14 days, bed rest for
3 days, and drinking warm beverages following delivery.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal
monitoring?
**Perform Leopold maneuvers.**
- The nurse should perform Leopold maneuvers to assess the position of the fetus
to best determine the optimal placement for the external fetal monitoring
transducer.
A nurse is caring for a client who is in active labor and has had no cervical change in
the last 4 hours. Which of the following statements should the nurse make?
**”Your provider will insert an intrauterine pressure catheter to monitor the
strength of your contractions.”**
- Insertion of an intrauterine pressure catheter is necessary to determine uterine
contraction intensity, which will identify whether or not the contractions are
adequate for the progression of labor.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic
shock. After notifying the provider, which of the following actions should the nurse take
next?
**Massage the client’s fundus.**
- The greatest risk to the client is hemorrhage. Therefore, the next action the nurse
should take is to massage the client’s fundus to expel clots and promote
contractions.
