ATI Maternal Newborn Final Exam 100% Questions and Answers

ATI Maternal Newborn Final Exam 100% Questions and Answers ATI Maternal Newborn Final Exam 100% Questions and Answers ATI Maternal Newborn Final Exam 100% Questions and Answers 1. A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above to the the right of umbilicus, mod- erate lochia rubra with small clots, temp 37.3 (99.2 F), pulse 52/min. Which of the following actions should the nurse take? A. report vital signs to the provider B. massage the fundus C. ask client when she last voided D. administer oxytocin agent ANS C. ask the client when she last voided Fundus is easily displaced when the bladder is full. Should be found firm at midline. 2. A nurse is preparing to administer naloxone to a newborn. which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. maternal drug use C. hyaline membrane disease D. meconium aspiration ANS A. IV narcotics administered to the mother during labor Should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor 3. A nurse is discussing anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make? A. an epidural given too early in labor can cause maternal hypertension B. an epidural given too early during labor will not be effective in active labor C. an epidural given too early can cause fetal depression D. an epidural given too early can prolong labor ANS D. an epidural given too early can prolong labor Clients who receive anesthesia before the active phase of labor usually find the progression to be slow. The medication depresses the CNS, so it takes longer for the cervix to dilate and efface 4. A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client? A. you should eat some crackers before rising from bed in the morning B. you should eat foods served at warm temperature C. you should sip whole milk withe breakfast D. you should brush your teeth immediately after meals ANS A. you should eat some crackers before rising from bed in the morning morning sickness is caused by the buildup of hcg in the mother's system. dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant. 5. A nurse is planning care for a client who is pregnant and is Rh-. In which of the following situations should the nurse administer Rhogam? A. while the client is in labor B. following an episode of influenza during pregnancy C. prior to a blood transfusion D. at 28 weeks of gestation ANS D. at 28 weeks of gestation Rhogam consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production 6. A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. respiratory depression B. hypothermia C. hypoglycemia D. jaundice ANS A. respiratory depression Magnesium sulfate can cause resp. and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of resp. depression 7. A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? A. promoting maternal-newborn bonding B. tight swaddling of the newborn C. small frequent feedings D. frequent stimulation ANS D. frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyper- active behaviors 8. A nurse is caring for a client who is in labor. A vaginal examination reveals the following info 2 cm, 50%, +1 right occiput anterior. Based on this info, which of the following fetal positions should the nurse document in the medical record? A. transverse B. breech C. vertex D. mentum ANS C. vertex ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex 9. A nurse is caring for a client who desires an IUD for contraception. Which of the following findings is a contraindication for the use of this device? A. htn B. menorrhagia C. history of multiple gestations D. history of thromboembolic disease ANS C. menorrhagia contraindication for women who have menorrhagia, severe dysmenorrhea, history of ectopic pregnancy 10. A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care? A. keep four side rails up while the client is in bed B. monitor FHR every hour C. insert indwelling urinary catheter D. check the cervix prior to analgesic administration ANS D. check the cervix prior to analgesic administration The nurse must know how many cm the cervix is dilated prior to analgesic ad- ministration during active labor. If administred too close to the time of delivery, the analgesic could cause resp. depression in the newborn 11. A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following should the nurse provide to the cilent about the treatment plan? A. your partner needs to be cultured and be treated with metronidazole only if his cultures are positive B. you and your partner need to take the medication and use a condom during intercourse until cultures are negative C. if both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse D. only you will need to take the metronidazole, but you should not have intercourse until your culture is negative ANS B. you and your partner need to take the medication and use a condom during intercourse until cultures are negative Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Easily treated with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated. 12. A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia? A. a newborn who is large for gestational age B. a newborn who has an Rh incompatibility C. a newborn who has pathologic jaundice D. a newborn who has fetal alcohol syndrome ANS A. a newborn who is large for gestational age LGA newborns are those whose weight is at or above the 90th percentile. One of the most common etiologies of LGA is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypo- glycemia. Other newborns at risk for hypoglycemia are SGA, premature newborns, and newborns who have perinatal hypoxia. 13. A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? A. check for a full bladder B. massage the fundus C. measure vital signs D. administer carboprost IM ANS B. massage the fundus The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. The greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first. 14. A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. turn the client on her left side B. palpate the client's uterus C. administer o2 to the client D. increase the client's IV fluids ANS A. turn the client onto her left side Late decelerations indicate that the client is experiencing uteroplacental insuffi- ciency. The client might be experiencing pressure on the inferior vena cava, which decreases teh o2 to the placenta and thus the fetus. Turning the client on her left side will relieve the pressure and facilitate better flood flow to the placenta, therby increasing the fetal o2 supply 15. A nurse is planning care for a client who has a prescription for oxytocin. which of the following is a contraindication for the use of this medication? A. prolonged rupture of membranes at 38 weeks of gestation B. intrauterine growth restriction C. postterm pregnancy D. active genital herpes ANS D. active genital herpes The newborn can acquire genital herpes as they pass through the birth canal, so oxytocin is contraindicated. A c-section is recommended if genital herpes is active 16. A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. extended periods of sleep B. poor muscle tone C. respiratory rate 50/min D. exaggerated reflexes ANS D. exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the CNS. Exaggerated reflexes are indicative of CNS irritability. Newborn would also have increased muscle tone, respiratory distress with rate greater than 60/min, 17. A nurse receives report on a client who is in labor and is experiencing contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? A. contractions that last for 60 seconds each with a 4-min rest between contractions B. contractions that last for 60 seconds each with a 3-min rest between contractions C. a contraction that lasts 4 min followed by a period of relaxation D. contractions that last 45 seconds each with a 3-min rest between con- tractions ANS B. contractions that last for 60 seconds each with a 3-min rest between contractions 18. A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. anemia B. frequent urinary tract infections C. previous c-section D. pelvic inflammatory disease (PID) ANS D. PID The most common site in ectopic pregnancies is within a fallopian tube, but can also occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. 19. A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make? A. have you told your husband about these feeligns B. these feelings are quite normal at the beginning of pregnancy C. perhaps you should see a counselor to discuss these feelings D. i am quite concerned about these feelings. could you explain more? ANS B. these feelings are quite normal at the beginning of pregnancy The client needs reassurance that these feelings are normal and there is no reason for concern. 20. A nurse is assessing a newborn who is 12 hr old and noes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. administer phytonadione IM B. obtain a stat prescription for a bilirubin level C. obtain a bagged urine specimen perform a gestational age assessment ANS B. obtain a stat prescription for a bilirubin level