1
VATI RN Maternal Newborn Assessment
A charge nurse is discussing care of clients who are in labor with a newly
R
licensed nurse. Which of the following actions should the charge nurse include in
E
the teaching regarding situations requiring an amniotomy? - ANS Placing a
H
fetal scalp electrode.
IG
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the
following statements should the charge nurse make? - ANS A chancre
H
lesion appears within 90 day after infection during the primary stage.
G
A charge nurse is providing teaching to a newly licensed nurse who is caring for
N
I
a client who has postpartum hemorrhagic shock. Which of the following
statements should the charge nurse make? - ANS The most accurate
Y
indication of organ perfusion is a clients urine output.
FL
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? - ANS
Encourage client who are prescribed methadone to breastfeed.
, 2
A client who is in active labor is admitted to a labor and delivery unit and reports,
"My water just broke and my baby is breech." Which of the following actions
should the nurse take first? - ANS Check fetal heart tones.
R
A nurse is admitting a client who is at 39wks of gestation and in active labor. The
E
client reports being positive for group B streptococcus (GBS) when screened at
H
36wks of gestation. Which of the following actions should the nurse expect to
take? - ANS Administer IV antibiotic prophylaxis.
IG
A nurse is assessing a 1-hr-old newborn. Which of the following findings should
H
the nurse report to the provider? - ANS Generalized petechiae
G
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago.
N
Identify the level in the abdomen a nurse should expect to find the client's uterus
I
when assessing the fundus. - ANS C is correct.
Y
-Immediately after birth, the fundus should be firm, midline with the umbilicus,
L
and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the
F
nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs
the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway
between the symphysis pubis and the umbilicus by 6 days postpartum.
A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units
packed RBCs due to a postpartum hemorrhage. Which of the following findings is
, 3
the best indication of adequate perfusion and oxygenation? - ANS Urinary
output.
A nurse is assessing a client who has genital herpes. Which of the following
R
findings should the nurse expect? - ANS Ulcerated lesions on the labia.
HE
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
G
the clients respiratory rate is 10/min. Which of the following actions should the
I
nurse take first? - ANS Administer oxygen by nonrebreather face mask.
GH
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? -
N
ANS Painless vaginal bleeding.
YI
A nurse is assessing a client who has preeclampsia and received a dose a
L
calcium gluconate to treat magnesium sulfate toxicity. Which of the following
F
findings should the nurse identify as an indication that calcium gluconate was
effective? - ANS Respiratory rate 12/min
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal
pad in 15min. The clients skin is cool and clammy to touch. Which of the
VATI RN Maternal Newborn Assessment
A charge nurse is discussing care of clients who are in labor with a newly
R
licensed nurse. Which of the following actions should the charge nurse include in
E
the teaching regarding situations requiring an amniotomy? - ANS Placing a
H
fetal scalp electrode.
IG
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the
following statements should the charge nurse make? - ANS A chancre
H
lesion appears within 90 day after infection during the primary stage.
G
A charge nurse is providing teaching to a newly licensed nurse who is caring for
N
I
a client who has postpartum hemorrhagic shock. Which of the following
statements should the charge nurse make? - ANS The most accurate
Y
indication of organ perfusion is a clients urine output.
FL
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? - ANS
Encourage client who are prescribed methadone to breastfeed.
, 2
A client who is in active labor is admitted to a labor and delivery unit and reports,
"My water just broke and my baby is breech." Which of the following actions
should the nurse take first? - ANS Check fetal heart tones.
R
A nurse is admitting a client who is at 39wks of gestation and in active labor. The
E
client reports being positive for group B streptococcus (GBS) when screened at
H
36wks of gestation. Which of the following actions should the nurse expect to
take? - ANS Administer IV antibiotic prophylaxis.
IG
A nurse is assessing a 1-hr-old newborn. Which of the following findings should
H
the nurse report to the provider? - ANS Generalized petechiae
G
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago.
N
Identify the level in the abdomen a nurse should expect to find the client's uterus
I
when assessing the fundus. - ANS C is correct.
Y
-Immediately after birth, the fundus should be firm, midline with the umbilicus,
L
and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the
F
nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs
the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway
between the symphysis pubis and the umbilicus by 6 days postpartum.
A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units
packed RBCs due to a postpartum hemorrhage. Which of the following findings is
, 3
the best indication of adequate perfusion and oxygenation? - ANS Urinary
output.
A nurse is assessing a client who has genital herpes. Which of the following
R
findings should the nurse expect? - ANS Ulcerated lesions on the labia.
HE
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
G
the clients respiratory rate is 10/min. Which of the following actions should the
I
nurse take first? - ANS Administer oxygen by nonrebreather face mask.
GH
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? -
N
ANS Painless vaginal bleeding.
YI
A nurse is assessing a client who has preeclampsia and received a dose a
L
calcium gluconate to treat magnesium sulfate toxicity. Which of the following
F
findings should the nurse identify as an indication that calcium gluconate was
effective? - ANS Respiratory rate 12/min
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal
pad in 15min. The clients skin is cool and clammy to touch. Which of the
