VATI RN Maternal Newborn Q&A (With Explanations)
-A charge nurse is teaching a newly licensed nurse about substance use disorders
during pregnancy. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
(( Answer)) Encourage client who are prescribed methadone to breastfeed.
Rationale
The nurse should encourage clients who are prescribed methadone during pregnancy
to breastfeed their newborns to help with withdrawal symptoms.)
-A nurse is caring for a client who received terbutaline subcutaneously. Which of the
following findings is an indication the medication was effective?
(( Answer)) Decreased frequency of contractions.
Rationale
Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause
relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse
should identify that a decrease in frequency of contractions is an indication that
terbutaline was effective.)
-A charge nurse is discussing care of clients who are in labor with a newly licensed
nurse. Which of the following actions should the charge nurse include in the teaching
regarding situations requiring an amniotomy?
(( Answer)) Placing a fetal scalp electrode.
Rationale
A fetal scalp electrode is attached to the presenting part of the fetus in order to provide
accurate continuous monitoring of the fetal heart rate. If the client's membranes are
intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to
enable access to the presenting part.)
-A nurse is reviewing the medical record of a client who has preeclampsia prior to
administering labetalol. For which of the following findings should the nurse withhold the
medication?
(( Answer)) Heart rate 54/min
Rationale
The nurse should identify that a heart rate of 54/min is below the expected reference
range of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to
increased blood volume and increase tissue demands for oxygen. Bradycardia is a
contraindication for the administration of labetalol, an antihypertensive medication.
Therefore, the nurse should withhold the medication and notify the provider.)
,-A nurse is caring for a client who is at 30 weeks of gestation and observes the client
choking while eating lunch. The client is unable to speak or cough. Identify the
sequence of steps the nurse should take to clear the airway obstruction.
(( Answer)) 1. Stand posterior to the client.
2. Position arms under the client's axilla and across the client's chest.
3. Place thumb-side of a clenched fist to the client's mid-sternum area.
4. Initiate chest thrust to the client using a backward motion.
Rationale
If the client becomes unconscious, the nurse should perform CPR and activate
emergency medical services.)
-A nurse is preparing to administer an opioid analgesic to a client who is in active labor.
Which of the following assessments should the nurse perform? (SATA)
(( Answer)) Maternal blood pressure.
Rationale
Opioid analgesic can cause hypotension. The nurse should assess the clients blood
pressure before and after administering opioids.
Pain level.
-The nurse should assess the clients baseline pain level prior to administering pain
medication and again after administering pain medication to determine the effectiveness
of the medication. Opioid analgesic are indicated for the relief of moderate to sever
labor pain.
(( Answer))Fetal heart rate.
Rationale
Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse
should assess the fetal heart rate prior to administering an opioid analgesic to ensure
the rate is within the expedited reference range and to have a baseline for future
assessments. The nurse should provide ongoing assessments of fetal heart rate
throughout labor according to facility protocol.)
-A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which
of the following findings should the nurse identify as a risk factor for developing
preeclampsia?
(( Answer)) Rheumatoid Arthritis.
Rationale
The presence of a connective tissue disease, such as rheumatoid arthritis or systemic
lupus erythematosus, increase a clients risk for developing preeclampsia.)
-A nurse is reviewing the laboratory results for a postpartum client who is receiving
warfarin for deep-vein thrombosis. Which of the following laboratory tests should the
nurse monitor?
(( Answer)) International normalized ratio (INR).
Rationale
The nurse should monitor the INR of a client who is taking warfarin. Prothrombin
time(PT) is also measure to regulate warfarin therapy. However, PT values are more
difficult to interpret. INR determined by multiplying the PT by a correction factor based
, on the specific thromboplastin preparation used for the test, as a way of equalizing
laboratory to laboratory variations.)
-A nurse is monitoring a client who is in the active phase of labor and has an
intrauterine pressure catheter and fetal scalp electrode. Which of the following findings
should the nurse expect?
(( Answer)) Montevideo units (MVU) of 220 mm Hg.
Rationale
The nurse should identify that an MVU of 220 mm Hg is within the expected range
during the active phase of labor. MVUs generally range between 100 to 250 mm Hg
during the first stage of labor and increase to 300 to 400 mm Hg during the second
stage of labor. MVUs are calculated by subtracting the baseline uterine pressure from
the peak contraction pressure for every contraction that occurs during a 10-min period.
The nurse then adds the pressure produced by each contraction during that time to
determine the MVUs.)
-A nurse is assessing a client who has just undergone a cesarean birth and was given
epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients
respiratory rate is 10/min. Which of the following actions should the nurse take first?
(( Answer)) Administer oxygen by nonrebreather face mask.
Rationale
The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to administer oxygen by nonrebreather mask to treat
manifestations of respiratory depression due to morphine administration.)
-A nurse is assessing a client who has placenta previa and is receiving fetal monitoring.
Which of the following clinical findings should the nurse expect?
(( Answer)) Painless vaginal bleeding.
Rationale
The placenta implants in the lower uterine segment, partially or completely covering the
cervix. With cervical changes, the placental blood vessels can tear, which results in
bleeding.)
-A nurse is assessing a client who is at 33wks of gestation. Which of the following
findings should the nurse report to the provider?
(( Answer)) Episodes of blurred vision.
Rationale
Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased
perfusion to the retina cause visual disturbances, such as blurred vision, double vision,
or dark spots in the visual field.)
-A nurse is assessing a client who is at 8wks of gestation and has hyperemesis
gravidarum. Which of the following are findings of this condition? (SATA)
(( Answer)) 1. Tachycardia.
Rationale
-A charge nurse is teaching a newly licensed nurse about substance use disorders
during pregnancy. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
(( Answer)) Encourage client who are prescribed methadone to breastfeed.
Rationale
The nurse should encourage clients who are prescribed methadone during pregnancy
to breastfeed their newborns to help with withdrawal symptoms.)
-A nurse is caring for a client who received terbutaline subcutaneously. Which of the
following findings is an indication the medication was effective?
(( Answer)) Decreased frequency of contractions.
Rationale
Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause
relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse
should identify that a decrease in frequency of contractions is an indication that
terbutaline was effective.)
-A charge nurse is discussing care of clients who are in labor with a newly licensed
nurse. Which of the following actions should the charge nurse include in the teaching
regarding situations requiring an amniotomy?
(( Answer)) Placing a fetal scalp electrode.
Rationale
A fetal scalp electrode is attached to the presenting part of the fetus in order to provide
accurate continuous monitoring of the fetal heart rate. If the client's membranes are
intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to
enable access to the presenting part.)
-A nurse is reviewing the medical record of a client who has preeclampsia prior to
administering labetalol. For which of the following findings should the nurse withhold the
medication?
(( Answer)) Heart rate 54/min
Rationale
The nurse should identify that a heart rate of 54/min is below the expected reference
range of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to
increased blood volume and increase tissue demands for oxygen. Bradycardia is a
contraindication for the administration of labetalol, an antihypertensive medication.
Therefore, the nurse should withhold the medication and notify the provider.)
,-A nurse is caring for a client who is at 30 weeks of gestation and observes the client
choking while eating lunch. The client is unable to speak or cough. Identify the
sequence of steps the nurse should take to clear the airway obstruction.
(( Answer)) 1. Stand posterior to the client.
2. Position arms under the client's axilla and across the client's chest.
3. Place thumb-side of a clenched fist to the client's mid-sternum area.
4. Initiate chest thrust to the client using a backward motion.
Rationale
If the client becomes unconscious, the nurse should perform CPR and activate
emergency medical services.)
-A nurse is preparing to administer an opioid analgesic to a client who is in active labor.
Which of the following assessments should the nurse perform? (SATA)
(( Answer)) Maternal blood pressure.
Rationale
Opioid analgesic can cause hypotension. The nurse should assess the clients blood
pressure before and after administering opioids.
Pain level.
-The nurse should assess the clients baseline pain level prior to administering pain
medication and again after administering pain medication to determine the effectiveness
of the medication. Opioid analgesic are indicated for the relief of moderate to sever
labor pain.
(( Answer))Fetal heart rate.
Rationale
Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse
should assess the fetal heart rate prior to administering an opioid analgesic to ensure
the rate is within the expedited reference range and to have a baseline for future
assessments. The nurse should provide ongoing assessments of fetal heart rate
throughout labor according to facility protocol.)
-A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which
of the following findings should the nurse identify as a risk factor for developing
preeclampsia?
(( Answer)) Rheumatoid Arthritis.
Rationale
The presence of a connective tissue disease, such as rheumatoid arthritis or systemic
lupus erythematosus, increase a clients risk for developing preeclampsia.)
-A nurse is reviewing the laboratory results for a postpartum client who is receiving
warfarin for deep-vein thrombosis. Which of the following laboratory tests should the
nurse monitor?
(( Answer)) International normalized ratio (INR).
Rationale
The nurse should monitor the INR of a client who is taking warfarin. Prothrombin
time(PT) is also measure to regulate warfarin therapy. However, PT values are more
difficult to interpret. INR determined by multiplying the PT by a correction factor based
, on the specific thromboplastin preparation used for the test, as a way of equalizing
laboratory to laboratory variations.)
-A nurse is monitoring a client who is in the active phase of labor and has an
intrauterine pressure catheter and fetal scalp electrode. Which of the following findings
should the nurse expect?
(( Answer)) Montevideo units (MVU) of 220 mm Hg.
Rationale
The nurse should identify that an MVU of 220 mm Hg is within the expected range
during the active phase of labor. MVUs generally range between 100 to 250 mm Hg
during the first stage of labor and increase to 300 to 400 mm Hg during the second
stage of labor. MVUs are calculated by subtracting the baseline uterine pressure from
the peak contraction pressure for every contraction that occurs during a 10-min period.
The nurse then adds the pressure produced by each contraction during that time to
determine the MVUs.)
-A nurse is assessing a client who has just undergone a cesarean birth and was given
epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients
respiratory rate is 10/min. Which of the following actions should the nurse take first?
(( Answer)) Administer oxygen by nonrebreather face mask.
Rationale
The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to administer oxygen by nonrebreather mask to treat
manifestations of respiratory depression due to morphine administration.)
-A nurse is assessing a client who has placenta previa and is receiving fetal monitoring.
Which of the following clinical findings should the nurse expect?
(( Answer)) Painless vaginal bleeding.
Rationale
The placenta implants in the lower uterine segment, partially or completely covering the
cervix. With cervical changes, the placental blood vessels can tear, which results in
bleeding.)
-A nurse is assessing a client who is at 33wks of gestation. Which of the following
findings should the nurse report to the provider?
(( Answer)) Episodes of blurred vision.
Rationale
Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased
perfusion to the retina cause visual disturbances, such as blurred vision, double vision,
or dark spots in the visual field.)
-A nurse is assessing a client who is at 8wks of gestation and has hyperemesis
gravidarum. Which of the following are findings of this condition? (SATA)
(( Answer)) 1. Tachycardia.
Rationale
