VATI RN Maternal Newborn 2019 Questions And Answers| 100% correct
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? Correct Answer: Encourage client who are prescribed methadone to breastfeed.
-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? Correct Answer: Decreased frequency of contractions.
-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? Correct Answer: Placing a fetal scalp electrode.
-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? Correct
Answer: Heart rate 54/min
-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. Correct 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.
-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) Correct Answer: Maternal blood pressure.
-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.
Fetal heart rate.
-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? Correct Answer:
Rheumatoid Arthritis.
-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? Correct Answer:
International normalized ratio (INR).
-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? Correct
Answer: Montevideo units (MVU) of 220 mm Hg.
- 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? Correct Answer: Administer oxygen by nonrebreather
face mask.
-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? Correct Answer: Painless vaginal bleeding.
-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? Correct Answer: Episodes of blurred vision.
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? Correct Answer: Encourage client who are prescribed methadone to breastfeed.
-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? Correct Answer: Decreased frequency of contractions.
-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? Correct Answer: Placing a fetal scalp electrode.
-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? Correct
Answer: Heart rate 54/min
-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. Correct 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.
-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) Correct Answer: Maternal blood pressure.
-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.
Fetal heart rate.
-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? Correct Answer:
Rheumatoid Arthritis.
-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? Correct Answer:
International normalized ratio (INR).
-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? Correct
Answer: Montevideo units (MVU) of 220 mm Hg.
- 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? Correct Answer: Administer oxygen by nonrebreather
face mask.
-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? Correct Answer: Painless vaginal bleeding.
-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? Correct Answer: Episodes of blurred vision.
