ATI MATERNAL NEWBORN PROCTORED EXAM

1. A nurse is assessing a client who has gestational diabetes and is experiencinghyperglycemia. Which of the following findings should the nurse expect? a. Reports increased urinary output b. Diaphoresis c. Reports blurred vision d. Shallow respirations 2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? a. Administer penicillin G 2.4 million units IM to the client b. Instruct the client to schedule an annual pelvic examination c. Tell the client she will start medication for HIV immediately after delivery d. Report the client’s condition to the local health department 3. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverseeffect of this medication? a. Depression b. Polyuria c. Hypotension d. Urticaria 4. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a newprescription for misoprostol. Which of the following instructions should the nurse include in the teaching? a. “I can administer oxytocin 4 hours after the insertion of the medication” b. “You will need a full bladder prior to the insertion of the medication” - no need toempty bladder first c. “Remain in a side-lying position for 15 minutes after the medication is inserted” d. “An antacid will be given 20 minutes prior to the insertion of the medication” 5. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? a. Administer antiviral medication b. Schedule an ultrasound examination c. Administer Haemophilus influenza type b vaccine d. Schedule an indirect Coombs’test 6. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Whichof the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Apply a cool back for 10 minutes to the heel prior to the puncture b. Request a prescription for IM analgesic c. Use a manual lace blade to pierce the skin d. Place the newborn skin to skin on the mother’s chest 7. A nurse is performing a vaginal examination on a client who is in labor and observes theumbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? ATI MATERNAL NEWBORN PROCTORED EXAM a. Insert two gloved fingers into the vagina and apply upward pressure to thepresenting part b. Wrap the visible cord tightly with sterile, dry gauze c. Apply oxygen to the client at 2 L/min via nasal cannula d. Place the client in the lithotomy position and apply fundal pressure 8. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption? Which of the following laboratory tests should the nurse expect theprovider to prescribe? a. Kleihauer-Betke test b. Progesterone serum level c. Lecithin/sphingomyelin (L/S) ration d. Maternal Alpha-fetoprotein (AFP) 9. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. Forwhich of the following complications should the nurse assess? a. Abruptio placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia 10. A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? a. 2+ deep tendon reflex b. Proteinuria of 200mg in a 24-hr specimen c. Polyuria d. Blurred vision 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. Incorrect: Numerous clots are abnormal and should be reported to the physician. Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. Correct: Lochia normally lasts for about 21 days, and changes from a bright red, topinkish brown, to creamy white. 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? Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. Incorrect: Variable decelerations (not late decelerations) are associated with cord compression. Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. Correct: Late decelerations are associated with uteroplacental insufficiency and are a signof fetal hypoxia. Repeated late decelerations indicate fetal distress. 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? Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions. Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions. Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of theclient and the family will be high. Inserting an indwelling catheter helps to keep thebladder empty and free from injury when the incision is made. Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case. 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. A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "The circumcision will heal completely within a couple of weeks." d. "I can give him a tub bath in two days." d. "I can give him a tub bath in two days." The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks. A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner will put the condom on while his penis is erect." b. "I will remove the condom 30 minutes after intercourse." c. "My partner should leave an empty space at the tip." d. "I can use spermicidal gels or creams to increase effectiveness." b. "I will remove the condom 30 minutes after intercourse." To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina. A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "What happens to your contractions when you move about?" d. "Have you felt fetal movement over the last 24 hours?" b. "Have you noticed any bloody show or fluid coming from your vagina?" Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent