Maternal newborn ati proctored exam Questions
And Answers Verified 100% Correct
The nurse should report a urinary output of 20 mL/hr because this can indicate
inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A
decrease in urinary output can also indicate a decrease in renal perfusion secondary to
a worsening of the client's pre-eclampsia.
A nurse is teaching a client who is at 13 wks gestation about the treatment of
incompetent cervix with cervical cerclage. What statement by the client indicates an
understanding of teaching?
a. I should go to the hospital if I think I may be in labor
b. I should expect bright red bleeding while the cerclage is in place
c. I am sad that I won't be able to get pregnant again
d. I can resume having sex as soon as I feel up to it - ANSWER a. I should go to the
hospital if I think I may be in labor
Cervical cerclage prevents premature opening of the cervix during pregnancy. The
client should immediately go to a facility for evaluation if she experiences any
manifestations of labor while the cerclage is in place. If the client experiences preterm
uterine contractions she might require tocolytic therapy.
A nurse is admitting a client who is in labor and experiencing moderate bright
red vaginal bleeding. What action should the nurse take? a. obtain blood
samples for baseline lab values
b. place a spiral electrode on the fetal presenting part
c. prepare the client for a transvaginal ultrasound
d. perform a vaginal exam to determine cervical dilation - ANSWER a. obtain blood
samples for baseline lab values
The nurse should obtain samples of the client's blood for baseline testing of hemoglobin
and hematocrit levels.
A nurse is caring for a client who is at 38 wks of gestation and reports no fetal
movement for 24 hr. What action should the nurse take?
a. auscultate for a FHR
b. reassure the client that a term fetus is less active
c. have the client drink orange juice
d. palpate the uterus for fetal movement - ANSWER a. auscultate for a FHR
,Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The
nurse should auscultate for the fetal heart rate using a Doppler device or an external
fetal monitor. This is the priority nursing action.
A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia.
What assessment provides the most accurate info regarding the client's fluid and
electrolyte status.
a. daily wt
b. bp
c. severity of edema
d. I&O - ANSWER a. daily wt
A nurse is teaching a client who is at 30 wks gestation about warning signs of
complications that she should report to her provider. What finding should the nurse
include in the teaching?
a. 10 fetal movements per hour
b. mild constipation
c. vaginal bleeding
d. nasal congestion - ANSWER c. vaginal bleeding
Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a
complication such as placental abruption, placenta previa, or preterm labor.
A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about
potential effects of the fibroid during pregnancy. What info should the nurse include?
a. you will have to undergo a c-section birth because of the fibroid
b. the fibroid can increase the risk for postpartum hemorrhage
c. the fibroid will shrink during pregnancy
d. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid -
ANSWER b. the fibroid can increase the risk for postpartum hemorrhage
A nurse is caring for a client who is at 26 wks gestation and reports constipation. What
responses by the nurse is appropriate?
a. you should drink 1 ounce of mineral oil q morning
b. you should eat at least 3 ounces of red meat/day
c. you should walk for at least 30 minutes q day
d. you should stop taking your prenatal - ANSWER c. you should walk for at least 30
minutes q day
The nurse should encourage the client to participate in moderate physical activity, such
as walking or swimming, every day. This activity increases intestinal peristalsis, which
will help alleviate constipation.
,A nurse is planning care for a newborn who is receiving phototherapy for an elevated
bilirubin level. What action should the nurse take?
a. apply barrier ointment to the newborn's perianal region
b. offer the newborn glucose water between feedings
c. use photometer to monitor the lamp's energy
d. keep the newborn's eye patches on during feedings - ANSWER c. use
photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the
newborn is receiving the appropriate amount to be effective.
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet
that are cool and slightly blue What action should the nurse take?
a. check the newborns temp using temporal thermometer
b. place the naked newborn on the mothers bare chest and cover both with a blanket
c. apply an o2 hood over the newborns head and neck
d. give the newborn glucose water between feedings - ANSWER b. place
the naked newborn on the mothers bare chest and cover both with a blanket
Exposure to a cool environment causes vasoconstriction, which results in cool
extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother
helps stabilize his temperature and promotes bonding.
A nurse is caring for a newborn immediately following delivery. What actions should the
nurse take first?
a. place the newborn directly on the client's chest
b. administer erythromycin ophthalmic ointment
c. give the newborn vit K IM
d. perform a detailed physical assessment - ANSWER a. place the newborn
directly on the client's chest
the greatest risk to the newborn is cold stress, which increases the need for oxygen and
glucose. Placing the newborn directly on the client's chest will help maintain the
newborn's temperature.
A nurse is providing teaching to the parents of a newborn about home safety. What
statement by the parents indicates an understanding of the teaching?
a. I will use an infant carrier when I drive to places close to the house
b. I will tie my baby's pacifier around his neck with a piece of yarn
c. I will place my baby on his back when it is time for him to sleep
d. I will keep my babys crib close to heat vents to keep him warm - CORRECT
ANSWER c. I will place my baby on his back when it is time for him to sleep
, A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well
flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar
score should the nurse assign to the newborn?
a. 10
b. 9
c. 8
d. 7 - ANSWER b. 9
A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal
laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to
the right. The client reports a gush of blood when she ambulates and no bm since
delivery. What action should the nurse take?
a. notify the provider about the elevated temp
b. massage the client's fundus
c. administer bisacodyl supp
d. assist the client to empty her bladder - ANSWER d. assist the client to empty her
bladder
When the client's fundus is deviated to the right or left it can indicate that her bladder is
full. The nurse should assist the client to empty her bladder to prevent uterine atony and
excessive lochia.
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who
weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse
administer? - ANSWER 0.25
A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow
respirations and periods of apnea lasting up to 10 seconds. What action should the
nurse take?
a. continue routine monitoring
b. place newborn prone
c. request a script for supplemental o2
d. perform chest percussion - ANSWER a. continue routine monitoring
The nurse should continue routine monitoring because the newborn's assessments
findings indicate he is adapting to extrauterine life.
placing in sidelying or supine
A nurse is caring for a client who reports intestinal gas pain following a c-section. What
action should the nurse take?
a. encourage client to drink carbonated beverages
b. instruct the client to splint the incision with a pillow
And Answers Verified 100% Correct
The nurse should report a urinary output of 20 mL/hr because this can indicate
inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A
decrease in urinary output can also indicate a decrease in renal perfusion secondary to
a worsening of the client's pre-eclampsia.
A nurse is teaching a client who is at 13 wks gestation about the treatment of
incompetent cervix with cervical cerclage. What statement by the client indicates an
understanding of teaching?
a. I should go to the hospital if I think I may be in labor
b. I should expect bright red bleeding while the cerclage is in place
c. I am sad that I won't be able to get pregnant again
d. I can resume having sex as soon as I feel up to it - ANSWER a. I should go to the
hospital if I think I may be in labor
Cervical cerclage prevents premature opening of the cervix during pregnancy. The
client should immediately go to a facility for evaluation if she experiences any
manifestations of labor while the cerclage is in place. If the client experiences preterm
uterine contractions she might require tocolytic therapy.
A nurse is admitting a client who is in labor and experiencing moderate bright
red vaginal bleeding. What action should the nurse take? a. obtain blood
samples for baseline lab values
b. place a spiral electrode on the fetal presenting part
c. prepare the client for a transvaginal ultrasound
d. perform a vaginal exam to determine cervical dilation - ANSWER a. obtain blood
samples for baseline lab values
The nurse should obtain samples of the client's blood for baseline testing of hemoglobin
and hematocrit levels.
A nurse is caring for a client who is at 38 wks of gestation and reports no fetal
movement for 24 hr. What action should the nurse take?
a. auscultate for a FHR
b. reassure the client that a term fetus is less active
c. have the client drink orange juice
d. palpate the uterus for fetal movement - ANSWER a. auscultate for a FHR
,Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The
nurse should auscultate for the fetal heart rate using a Doppler device or an external
fetal monitor. This is the priority nursing action.
A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia.
What assessment provides the most accurate info regarding the client's fluid and
electrolyte status.
a. daily wt
b. bp
c. severity of edema
d. I&O - ANSWER a. daily wt
A nurse is teaching a client who is at 30 wks gestation about warning signs of
complications that she should report to her provider. What finding should the nurse
include in the teaching?
a. 10 fetal movements per hour
b. mild constipation
c. vaginal bleeding
d. nasal congestion - ANSWER c. vaginal bleeding
Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a
complication such as placental abruption, placenta previa, or preterm labor.
A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about
potential effects of the fibroid during pregnancy. What info should the nurse include?
a. you will have to undergo a c-section birth because of the fibroid
b. the fibroid can increase the risk for postpartum hemorrhage
c. the fibroid will shrink during pregnancy
d. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid -
ANSWER b. the fibroid can increase the risk for postpartum hemorrhage
A nurse is caring for a client who is at 26 wks gestation and reports constipation. What
responses by the nurse is appropriate?
a. you should drink 1 ounce of mineral oil q morning
b. you should eat at least 3 ounces of red meat/day
c. you should walk for at least 30 minutes q day
d. you should stop taking your prenatal - ANSWER c. you should walk for at least 30
minutes q day
The nurse should encourage the client to participate in moderate physical activity, such
as walking or swimming, every day. This activity increases intestinal peristalsis, which
will help alleviate constipation.
,A nurse is planning care for a newborn who is receiving phototherapy for an elevated
bilirubin level. What action should the nurse take?
a. apply barrier ointment to the newborn's perianal region
b. offer the newborn glucose water between feedings
c. use photometer to monitor the lamp's energy
d. keep the newborn's eye patches on during feedings - ANSWER c. use
photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the
newborn is receiving the appropriate amount to be effective.
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet
that are cool and slightly blue What action should the nurse take?
a. check the newborns temp using temporal thermometer
b. place the naked newborn on the mothers bare chest and cover both with a blanket
c. apply an o2 hood over the newborns head and neck
d. give the newborn glucose water between feedings - ANSWER b. place
the naked newborn on the mothers bare chest and cover both with a blanket
Exposure to a cool environment causes vasoconstriction, which results in cool
extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother
helps stabilize his temperature and promotes bonding.
A nurse is caring for a newborn immediately following delivery. What actions should the
nurse take first?
a. place the newborn directly on the client's chest
b. administer erythromycin ophthalmic ointment
c. give the newborn vit K IM
d. perform a detailed physical assessment - ANSWER a. place the newborn
directly on the client's chest
the greatest risk to the newborn is cold stress, which increases the need for oxygen and
glucose. Placing the newborn directly on the client's chest will help maintain the
newborn's temperature.
A nurse is providing teaching to the parents of a newborn about home safety. What
statement by the parents indicates an understanding of the teaching?
a. I will use an infant carrier when I drive to places close to the house
b. I will tie my baby's pacifier around his neck with a piece of yarn
c. I will place my baby on his back when it is time for him to sleep
d. I will keep my babys crib close to heat vents to keep him warm - CORRECT
ANSWER c. I will place my baby on his back when it is time for him to sleep
, A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well
flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar
score should the nurse assign to the newborn?
a. 10
b. 9
c. 8
d. 7 - ANSWER b. 9
A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal
laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to
the right. The client reports a gush of blood when she ambulates and no bm since
delivery. What action should the nurse take?
a. notify the provider about the elevated temp
b. massage the client's fundus
c. administer bisacodyl supp
d. assist the client to empty her bladder - ANSWER d. assist the client to empty her
bladder
When the client's fundus is deviated to the right or left it can indicate that her bladder is
full. The nurse should assist the client to empty her bladder to prevent uterine atony and
excessive lochia.
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who
weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse
administer? - ANSWER 0.25
A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow
respirations and periods of apnea lasting up to 10 seconds. What action should the
nurse take?
a. continue routine monitoring
b. place newborn prone
c. request a script for supplemental o2
d. perform chest percussion - ANSWER a. continue routine monitoring
The nurse should continue routine monitoring because the newborn's assessments
findings indicate he is adapting to extrauterine life.
placing in sidelying or supine
A nurse is caring for a client who reports intestinal gas pain following a c-section. What
action should the nurse take?
a. encourage client to drink carbonated beverages
b. instruct the client to splint the incision with a pillow
