VATI Maternal Newborn Pre-Assessment
Test 2023-2024
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating
that she is "not really sure if she is in labor or not." Which of the following should the nurse
recognize as a sign of true labor?
A. Rupture of the membranes
B. Changes in the cervix
C. Station of the presenting part
D. Pattern of contractions - AnswersB. Changes in the cervix
Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate
indication of true labor.
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a
circumcision with the Plastibell technique. Which of the following client statements indicates
understanding of circumcision care? (Select all that apply.)
A. "I'll expect the plastic ring to fall off by itself within a week."
B. "I'll apply petroleum jelly to his penis with diaper changes."
C. "I'll wash his penis with warm water and mild soap each day."
D. "I'll call the doctor if I see any bleeding."
E. "I'll make sure his diaper is loose in the front." - AnswersA. "I'll expect the plastic ring to fall off by
itself within a week."
D. "I'll call the doctor if I see any bleeding."
, E. "I'll make sure his diaper is loose in the front."
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring
the uterine contractions, which of the following findings should the nurse report to the provider?
A. Contractions lasting longer than 90 seconds
B. Contractions occurring every 3 to 5 min
C. Contractions are strong in intensity
D. Client reports feeling contractions in lower back - AnswersA. Contractions lasting longer than 90
seconds
A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there
is inadequate uterine relaxation and should be reported to the provider.
In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min
intervals. This is an expected finding. This is an expected finding in a client who is moving from the
active to transition phase of the first stage of labor. It does not need to be reported to the provider.
This is an expected finding in a client who is in true labor. As the labor progresses, the contractions
radiate to the abdomen.
A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is
displaced to the right of midline, is firm, and is two fingerbreaths above the umbilicus. Which of the
following actions should the nurse complete at this time?
A. Massage the fundus
B. Insert a urinary catheter
C. Have the client urinate
D. Administer an analgesic - AnswersC. Have the client urinate
A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can
lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to
midline and remain below the umbilicus.
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a
new prescription for betamethasone and asks the nurse about the purpose of this medication. The
nurse should provide which of the following explanations?
Test 2023-2024
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating
that she is "not really sure if she is in labor or not." Which of the following should the nurse
recognize as a sign of true labor?
A. Rupture of the membranes
B. Changes in the cervix
C. Station of the presenting part
D. Pattern of contractions - AnswersB. Changes in the cervix
Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate
indication of true labor.
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a
circumcision with the Plastibell technique. Which of the following client statements indicates
understanding of circumcision care? (Select all that apply.)
A. "I'll expect the plastic ring to fall off by itself within a week."
B. "I'll apply petroleum jelly to his penis with diaper changes."
C. "I'll wash his penis with warm water and mild soap each day."
D. "I'll call the doctor if I see any bleeding."
E. "I'll make sure his diaper is loose in the front." - AnswersA. "I'll expect the plastic ring to fall off by
itself within a week."
D. "I'll call the doctor if I see any bleeding."
, E. "I'll make sure his diaper is loose in the front."
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring
the uterine contractions, which of the following findings should the nurse report to the provider?
A. Contractions lasting longer than 90 seconds
B. Contractions occurring every 3 to 5 min
C. Contractions are strong in intensity
D. Client reports feeling contractions in lower back - AnswersA. Contractions lasting longer than 90
seconds
A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there
is inadequate uterine relaxation and should be reported to the provider.
In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min
intervals. This is an expected finding. This is an expected finding in a client who is moving from the
active to transition phase of the first stage of labor. It does not need to be reported to the provider.
This is an expected finding in a client who is in true labor. As the labor progresses, the contractions
radiate to the abdomen.
A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is
displaced to the right of midline, is firm, and is two fingerbreaths above the umbilicus. Which of the
following actions should the nurse complete at this time?
A. Massage the fundus
B. Insert a urinary catheter
C. Have the client urinate
D. Administer an analgesic - AnswersC. Have the client urinate
A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can
lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to
midline and remain below the umbilicus.
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a
new prescription for betamethasone and asks the nurse about the purpose of this medication. The
nurse should provide which of the following explanations?
