ATI Maternal Newborn Proctored Exam
1. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate.
The client begins to show indications of magnesium sulfate toxicity. Which of the
following medications should the nurse prepare to administer?
- Correct Answer:
C. Calcium gluconate
The nurse should discontinue the magnesium sulfate infusion immediately and prepare
to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to
prevent cardiac and respiratory arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium
sulfate.
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and
alprazolam, not magnesium sulfate.
2. A nurse is providing postpartum discharge teaching to a client who is non-lactating
about breast discomfort relief measures. Which of the following pieces of information
should the nurse include?
- Correct Answer:
"Place fresh cabbage leaves on your breasts."
After 3 days postpartum, the client's breasts can become swollen and distended
because of congestion of the vascular structures of the breasts.
, Fresh cabbage leaves can be applied to engorged breasts to help relieve breast
discomfort.
The coolness of the leaves and the phytoestrogens exert a therapeutic effect on
engorged breasts.
Leaves should be replaced when they become wilted.
Incorrect Answers:
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate
engorgement and swelling.
C. Application of warmth to the breasts should be avoided because heat can stimulate
milk production. An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk
production rather than decrease it.
3. A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea
and vomiting. Which of the following statements should the nurse include in the
teaching?
- Correct Answer:
D.
"You should eat dry foods that are high in carbohydrates when you wake up."
The nurse should instruct the client to eat foods that are high in carbohydrates such as
dry toast or crackers upon waking or when nausea occurs.
Incorrect Answers:
A. The nurse should instruct the client to eat foods served at cool temperatures to
decrease nausea and vomiting.
, B. The nurse should instruct the client to avoid brushing her teeth immediately after
eating to decrease vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of
nausea.
4. A nurse is planning care for a newborn who is receiving phototherapy for an elevated
bilirubin level. Which of the following actions should the nurse take?
- D. Use a photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the
newborn is receiving the appropriate amount to be effective.
5. A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption.
Which of the following findings should the nurse expect?
- Dark red vaginal bleeding
The nurse should expect this client with a mild placental abruption to have minimal dark
red vaginal bleeding.
6. A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C).
Which of the following actions should the nurse perform?
- Correct Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased muscular and
metabolic activity. This process increases glucose consumption and puts the newborn at
risk of hypoglycemia.
, Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of
rectal perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection.
Additionally, there is a potential fire risk from the bassinet linens and the vent.
7. A nurse is providing postpartum discharge teaching for a client who is breastfeeding.
The client states, "I've heard that I can't use any birth control until I stop breastfeeding."
Which of the following responses should the nurse make?
- Correct Answer:
D.
"A progestin-only pill or injection is available for use while you are breastfeeding."
Progestin-only injections, implants, and birth control pills are acceptable options for
clients who are breastfeeding, although some experts recommend waiting until 6 weeks
postpartum to initiate the medication.
Incorrect Answers:
A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a
reliable and effective means of birth control. The client may experience an unplanned
pregnancy if she waits until her periods resume before considering birth control options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended for clients who are breastfeeding due to the risk of inhibiting breast milk
production and supply.
1. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate.
The client begins to show indications of magnesium sulfate toxicity. Which of the
following medications should the nurse prepare to administer?
- Correct Answer:
C. Calcium gluconate
The nurse should discontinue the magnesium sulfate infusion immediately and prepare
to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to
prevent cardiac and respiratory arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium
sulfate.
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and
alprazolam, not magnesium sulfate.
2. A nurse is providing postpartum discharge teaching to a client who is non-lactating
about breast discomfort relief measures. Which of the following pieces of information
should the nurse include?
- Correct Answer:
"Place fresh cabbage leaves on your breasts."
After 3 days postpartum, the client's breasts can become swollen and distended
because of congestion of the vascular structures of the breasts.
, Fresh cabbage leaves can be applied to engorged breasts to help relieve breast
discomfort.
The coolness of the leaves and the phytoestrogens exert a therapeutic effect on
engorged breasts.
Leaves should be replaced when they become wilted.
Incorrect Answers:
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate
engorgement and swelling.
C. Application of warmth to the breasts should be avoided because heat can stimulate
milk production. An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk
production rather than decrease it.
3. A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea
and vomiting. Which of the following statements should the nurse include in the
teaching?
- Correct Answer:
D.
"You should eat dry foods that are high in carbohydrates when you wake up."
The nurse should instruct the client to eat foods that are high in carbohydrates such as
dry toast or crackers upon waking or when nausea occurs.
Incorrect Answers:
A. The nurse should instruct the client to eat foods served at cool temperatures to
decrease nausea and vomiting.
, B. The nurse should instruct the client to avoid brushing her teeth immediately after
eating to decrease vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of
nausea.
4. A nurse is planning care for a newborn who is receiving phototherapy for an elevated
bilirubin level. Which of the following actions should the nurse take?
- D. Use a photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the
newborn is receiving the appropriate amount to be effective.
5. A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption.
Which of the following findings should the nurse expect?
- Dark red vaginal bleeding
The nurse should expect this client with a mild placental abruption to have minimal dark
red vaginal bleeding.
6. A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C).
Which of the following actions should the nurse perform?
- Correct Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased muscular and
metabolic activity. This process increases glucose consumption and puts the newborn at
risk of hypoglycemia.
, Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of
rectal perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection.
Additionally, there is a potential fire risk from the bassinet linens and the vent.
7. A nurse is providing postpartum discharge teaching for a client who is breastfeeding.
The client states, "I've heard that I can't use any birth control until I stop breastfeeding."
Which of the following responses should the nurse make?
- Correct Answer:
D.
"A progestin-only pill or injection is available for use while you are breastfeeding."
Progestin-only injections, implants, and birth control pills are acceptable options for
clients who are breastfeeding, although some experts recommend waiting until 6 weeks
postpartum to initiate the medication.
Incorrect Answers:
A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a
reliable and effective means of birth control. The client may experience an unplanned
pregnancy if she waits until her periods resume before considering birth control options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended for clients who are breastfeeding due to the risk of inhibiting breast milk
production and supply.
