ATI Maternity Newborn Proctored Exam 2024 with NGN Questions and Verified Rationalized Answers, 100% Guarantee Pass

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? X @ A. Discharge the client to home : ‘, ) B. Administer betamethasone __ C. Perform an amnioinfusion v ! D. Prepare for delivery of the infant Graded Response: Incorrect Correct Answer: D. Prepare for delivery of the infant Peer Comparison ®A Delivery is considered when a biophysical profile score of 6 or lower is obtained at or after 36 weeks of gestation or with a score of 4 or lower 8 .- at any gestational age. cll Incorrect Answers: D _ A. A biophysical profile score of 4 indicates possible chronic fetal asphyxia. It would not be appropriate to discharge the client to home. B. Betamethasone is administered to promote fetal lung development and to decrease the risk of respiratory distress syndrome if delivery is anticipated between 24 and 34 weeks of gestation. C. An amnioinfusion is performed during labor to relieve transient fetal hypoxia caused by umbilical cord compression. A nurse is assessing a client who is pregnant and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort? 3‘A ) A. Relaxin v {__ B.Estrogen __) C. Progesterone X @ D. Human chorionic somatomammotropin (HCS) Graded Response: Incorrect Correct Answer: B. Estrogen Peer Comparison Al Estrogen increases vascularity and connective tissue growth. Nasal stuffiness, a common discomfort in pregnancy, results from the increased . . s I vascularity of the mucus membranes within the nasal passages. c Il Incorrect Answers: ®D . A. Relaxin causes loosening of the ligaments, making the pelvic joints more flexible to facilitate the birthing process. C. Progesterone has a relaxant effect on smooth muscle, which helps the uterus remain relaxed and maintain the pregnancy. The effects of this hormone also contribute to the occurrence of constipation and heartburn during pregnancy. D. HCS is produced by the placenta and stimulates the maternal metabolism to supply nutrients for fetal growth. This hormone is additionally responsible for lactation development of the maternal breasts. A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? ! A. Withhold analgesics to prevent urinary retention v B. Run water in the sink while the client sits on the toilet X (Q) C. Perform Credé's maneuver every 4 hours (_) D. Restrict oral hydration Graded Response: Incorrect Correct Answer: B. Run water in the sink while the client sits on the toilet Peer Co Al Running water in the sink, placing the client's hand in warm water, and using a squeeze bottle to run water over the client's perineum can 5 . assist with spontaneous voiding. Incorrect Answers: A. The nurse should administer analgesics as needed to decrease the client's pain during voiding. C. Credé's maneuver is used for clients who are not expected to regain voluntary bladder control. D. Clients who are postpartum will have increased urine output and are at risk for bladder distention. Restricting oral hydration will not prevent bladder distention. A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? X (’) A. October 13 {_ ) B.November 13 v {_J C.October 27 {_ ) D. November 27 Graded Response: Incorrect Correct Answer: C. October 27 Peer Comparison ol Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and adding 7 days. 8 | incorrect Answers: c I A. An expected date of delivery of October 13 would follow a last menstrual period date of January 6. D I B. An expected date of delivery of November 13 would follow a last menstrual period date of February 6. D. An expected date of delivery of November 27 would follow a last menstrual period date of February 20. A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? X @) A. Post-term birth B. Macrosomia v ! C. Respiratory distress syndrome __J D. Maternal gestational diabetes Graded Response: Incorrect Correct Answer: C. Respiratory distress syndrome Peer Comparison or |} Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia. 5 . Incorrect Answers: C _ A. Preterm birth is a risk factor for NEC. Approximately 90% of cases of NEC occur in preterm newborns. D - B. Low birth weight and intrauterine growth restriction are risk factors for NEC. D. Maternal gestational diabetes is not a risk factor for NEC. Risk factors include asphyxia, gastrointestinal infection, and polycythemia. A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? 1‘_ _'3 A. They can cause increased pain from the cord. v |__ B.They can cause delayed cord separation. X (,) C. They can cause swelling of the surrounding tissue. N _bi D. They can cause skin discoloration. Graded Response: Incorrect Correct Answer: B. They can cause delayed cord separation. Peer Comparison A There is no evidence that antimicrobial preparations are of any benefit in the process of the drying and detachment of the umbilical cord 8 ._ stump. Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection. oc N Incorrect Answers: D I A. The tissue of the cord is no longer functioning; therefore, the cord cannot cause the newborn pain. C. Swelling around the cord is an indication of infection. Antimicrobial agents would not cause an infection, but the provider might prescribe them to treat the infection. D. Most antiseptics are colorless. Povidone-iodine is an exception, but it would only cause temporary discoloration from the antiseptic, not permanent discoloration of the skin. A nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. Which of the following actions should the nurse take to promote rotation of the fetal head? __ A. Apply counterpressure to the client’s back ___J B. Place heat on the client's lower back v {_ C.Instruct the client to squat during contractions X (:.) D. Encourage the client to ambulate in the hall Graded Response: Incorrect Correct Answer: C. Instruct the client to squat during contractions Peer Comparison - Measures to encourage rotation of the fetal head to a more anterior position include squatting during contractions, getting on hands and 8 | knees during contractions, and lying on the same side as the fetal spine. c I Incorrect Answers: ®D - A. Counterpressure to the back helps relieve pain due to pressure of the occiput on spinal nerves when the fetus is in an occiput posterior position, but it will not help rotate the fetal head. B. Heat application to the lower back can promote relaxation and relieve pain, but it will not help rotate the fetal head. D. Ambulation is helpful when membranes are intact and when the client has not received analgesia; however, it will not help rotate the fetal head. A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? X (§) A. Effacement 1 ) B. Dilation Vv ) C. Lightening 1 D. Quickening Graded Response: Incorrect Correct Answer: C. Lightening Peer Comparison or |} s ] c I Incorrect Answers: D . Lightening describes the engagement of the fetal head into the pelvis. When this occurs, breathing becomes easier, but urination is more frequent. A. Effacement is the thinning of the cervical tissue. B. Dilation is the widening of the cervix during labor. D. Quickening is the first occurrence of fetal movement. The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? v A. "The blood-tinged mucus is a result of pseudomenstruation.” 3 ! B. "The blood-tinged mucus indicates a urinary tract infection." X (Q C. "The blood-tinged mucus is due to uric acid crystals." __) D."The blood-tinged mucus is a result of the initial genital examination." Graded Response: Incorrect Correct Answer: A. "The blood-tinged mucus is a result of p seud struation." Pseudomenstruation is a result of the loss of maternal hormones at birth, resulting in vaginal discharge with withdrawal bleeding. Itis an expected finding in female newborns. Incorrect Answers: B. Aninfection in the urinary tract might cause blood in the urine but not blood from the vagina. C. Uric acid crystals can appear as pinkish spots on the diaper, but they are in the newborn's urine, not vaginal discharge. They are an expected finding during the first week after birth. D. Newborns undergo a comprehensive physical examination by the provider shortly after birth, including an examination of the genitalia. However, the examination should not cause traumatic vaginal bleeding. Peer Comparison ~ I e | oc o || A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? X (9> A. Wash the site with soap and warm water once daily ‘, / B. Gently remove the yellow exudate that forms around the site v |__ C.Avoid using diaper wipes on the site during diaper changes ) D. Apply the diaper tightly to apply pressure to the site Graded Response: Incorrect Correct Answer: C. Avoid using diaper wipes on the site during diaper changes The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation. Incorrect Answers: A. The parent should avoid using soap until the site heals, in about 1 week. B. The parent should not attempt to remove the yellow exudate from the circumcision site, as this could cause bleeding. D. The parent should apply the diaper loosely over the penis to avoid creating pressure on the circumcision site. A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? va A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure | B. Assess the fetal heart rate pattern for 10 min prior to the procedure X (Q) C. Position the client upright and erect on the edge of the bed prior to the procedure __/ D. Monitor vital signs every 15 min after the anesthetic is placed Graded Response: Incorrect Correct Answer: A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure The nurse should infuse a fluid bolus of 500 to 1,000 mL of 0.9% sodium chloride or lactated Ringer's 15 to 30 minutes before the procedure to offset the potential complication of hypotension. Incorrect Answers: B. The nurse should assess the fetal heart rate pattern for a minimum of 20 to 30 minutes prior to the procedure. C. The nurse should position the client with the spine flexed to open the intervertebral spaces and allow the placement of the spinal needle. D. The nurse should monitor the client's blood pressure, pulse, respirations, and fetal heart rate every 5 to 10 minutes after the introduction of the anesthetic agent. A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? v ) A. "I should stop swaddling my baby once she is able to roll over by herself" ! B. "My baby's legs should be extended straight out when | swaddle her." X (5) C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." 1 ! D. "After swaddling, | should place my baby on her side in her crib or bassinet." Graded Response: Incorrect Correct Answer: A. "l should stop swaddling my baby once she is able to roll over by herself." Peer Comparison ~ I The parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. Rolling over can 5 - tighten the swaddle and keep the baby from breathing properly. Incorrect Answers: D I B. The parent should avoid swaddling the newborn with the legs extended, as this can cause hip dislocation. The parent should swaddle the newborn with the hips slightly flexed and enough room in the blanket for the newborn to move the knees. C. The parent should be able to fit 2 to 3 fingers between the newborn's chest and the swaddled blanket. A swaddle that is too tight can interfere with respiration or cause the newborn to overheat. D. The parent should lay the newborn on her back after swaddling to reduce the risk of sudden infant death syndrome (SIDS). A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as an indication that the client understands the instructions? v A. "l can apply a heating pad to my back to relieve back pain." X @) B. "I can have a low spinal block to help with labor pain." C. "l can have butorphanol every 2 hours during labor." ' D. "My time limit for staying in the hydrotherapy tub is 30 minutes." Graded Response: Incorrect Correct Answer: A. "l can apply a heating pad to my back to relieve back pain." Peer Compariso Heat applications to the lower back can help promote relaxation and relieve pain because they reduce ischemia in the muscles and bring more blood flow to the area. The client should have 1 or 2 layers of cloth between her skin and the heating pad. Incorrect Answers: B. Low spinal anesthesia is useful during a vaginal birth, but it is not an appropriate method for managing labor pain. C. If the provider prescribes it, the client can receive butorphanol every 3 to 4 hours. D. Although most clients stay in the hydrotherapy tub for 30 to 60 minutes, there is no time limit for how long they may stay in the tub. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? X (Q A. “Stand under a hot shower with your breasts exposed.” v () B."Place ice packs on your breasts.” __/ C.*Wear a loose-fitting, comfortable bra.” ) D. “Limit fluid intake to 1 L per day.” Graded Response: Incorrect Correct Answer: B. “Place ice packs on your breasts.” Peer Comparison ol The nurse should instruct the client to place ice packs on her breasts using a “15 minutes on and 45 minutes off” schedule to decrease 5 _ swelling of the breast tissue as the body produces milk. I C Incorrect Answers: D | A. Warm water running over the breasts can stimulate milk production. C. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with milk. D. The client should drink 2 to 3 L of fluid per day to promote normal bowel function. A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication? X (Q) A. Prolonged rupture of membranes at 38 weeks gestation B. Intrauterine growth restriction 3 ! C. Post-term pregnancy v D. Active genital herpes Graded Response: Incorrect Correct Answer: D. Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection while passing through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection. Incorrect Answers: A. When the client is at or near term with prolonged rupture of membranes, oxytocin induction is indicated. B. Intrauterine growth restriction is an indication for the use of oxytocin to induce labor. C. Induction of labor with oxytocin is suggested in post-term pregnancies. A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions? 1 | A. Palpating the firmness of the uterus during a contraction X (§> B. Calculating the time from the end of each contraction to the beginning of the next ) C. Measuring the time from the beginning of a contraction to the end of that same contraction v __ D. Evaluating the time from the beginning of a contraction to the beginning of the next contraction Graded Response: Incorrect Correct Answer: D. Evaluating the time from the beginning of a contraction to the beginning of the next contraction The method for timing contractions is to measure the time from the beginning of one contraction to the beginning of the next. That time interval is the frequency of contractions at any given point in time. Incorrect Answers: A. This action will measure the intensity or strength of the contraction. B. Measuring the time from the end of one contraction to the beginning of the next should determine the resting period between contractions, not their frequency. C. Measuring the length of a contraction from beginning to end determines the duration of the contraction, not the frequency. A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? X @ A. Platelet count 97,000/mm*3 v (B Deep tendon reflexes 4+ X v () ¢.Urine protein 1+ () D.BUN 22 mg/dL Graded Response: Incorrect Correct Answer: B. Deep tendon reflexes 4+ Peer Comf o+l Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia 5 - with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures. Incorrect Answers: D I A. With preeclampsia, a client's platelet count is usually below 100,000/mm#*3. There is no need to report this finding. C. With preeclampsia, a client’s proteinuria is usually above 1+ on a urine reagent strip. There is no need to report this finding. D. With preeclampsia, a client's BUN level is usually above 20 mg/dL. There is no need to report this finding. A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? ( ,- _ A. Apply the diaper tightly over the circumcision area __/ B. Remove the yellow exudate with each diaper change (Q C. Use prepackaged commercial wipes to clean the circumcision site _ D. Encourage non-nutritive sucking for pain relief Graded Response: Incorrect Correct Answer: D. Encourage non-nutritive sucking for pain relief Peer Comparison A Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management. 5 I. Incorrect Answers: ecC I A. The parents should apply the diaper loosely to prevent pressure and injury to the circumcision area. D _ B. The yellow exudate that forms over the glans penis is part of the healing process and should not be removed. This usually continues for 2 to 3 days. C. The parents should not use prepackaged commercial wipes due to the alcohol content, which can delay healing and cause pain. The parents should use warm water to clean the penis gently. A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take? va / A. Place an opaque mask over the newborn's eyes ! B. Apply lotion to the newborn's skin twice daily 1 ) C. Dress the newborn in a diaper and t-shirt X @ D. Check the newborn's temperature twice daily Graded Response: Incorrect Correct Answer: A. Place an opaque mask over the newborn's eyes The nurse should cover the newborn's eyes with an opaque mask to prevent retinal damage from the ultraviolet light used in phototherapy. Incorrect Answers: B. The nurse should not apply lotions, creams, or ointments to the newborn's skin because they can absorb heat and cause burns. C. The nurse should dress the newborn in a diaper only to maximize skin exposure to the phototherapy light. D. The nurse should check the newborn's temperature frequently while receiving phototherapy. A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? X (.) A. Perform chest percussion __/ B. Place the newborn in a prone position v |_ C. Continue routine monitoring __J D. Request a prescription for supplemental oxygen Graded Response: Incorrect Correct Answer: C. Continue routine monitoring Peer Comparison @A The nurse should continue routine monitoring because the newborn’s assessment findings indicate adaptation to extrauterine life. I s | Incorrect Answers: C _ A. The nurse should expect short periods of apnea for a 12-hour-old newborn and should not perform chest percussion. D - B. The nurse should place the newborn in a side-lying position or supine to promote sleep and decrease the risk of respiratory distress. D. Manifestations of abnormal breathing patterns that can indicate a need for supplemental oxygen include tachypnea, nasal retractions, stridor, and gasping. A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? ' A. Ensure the client has a full bladder v ! B. Stand at the client's right side if the nurse is right-handed 1 ! C. Assist the client onto her back with knees extended. X (9) D. Palpate the outline of the fetus's head with the palms of the hands Graded Response: Incorrect Correct Answer: B. Stand at the client's right side if the nurse is right-handed The nurse should stand facing the client on the side that correlates with the nurse's dominant hand; therefore, if the nurse is right-handed, the nurse should stand at the client's right side. Incorrect Answers: A. The nurse should assist the client to empty her bladder prior to performing Leopold maneuvers. C. Placing the client in a supine position increases the risk of supine hypotension; therefore, the nurse should place a pillow under the client's head and a rolled towel under her hip with the knees flexed. D. The nurse should palpate the outline of the fetus's head with the fingertips. A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? X (Q) A. Gently retract the foreskin to wash the glans with soap and water v ) B. Sponge bathe the newborn every other day / C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F) Graded Response: Incorrect Correct Answer: B. Sponge bathe the newborn every other day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed. Incorrect Answers: A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. D. The parents should maintain the bath water temperature between 38° and 40°C (100° and 104°F). A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? v ) A. "Carbohydrates should make up 55% of your diet." X (@ B. "Protein should make up 70% of your diet." 3 ! C. "Fats should make up 45% of your diet." D. "Fiber should make up 10% of your diet." Graded Response: Incorrect Correct Answer: A. "Carbohydrates should make up 55% of your diet." Peer Comparison - I For clients who have pregestational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% ®B carbohydrates, 20% protein, 25% fat, and less than 10% saturated fat. IC Incorrect Answers: D . B. Protein should only make up 20% of the diet for clients who have pregestational diabetes. C. The ideal diet for clients who have pregestational diabetes contains 25% fat. D. There is no limitation on the amount of fiber a client who has pregestational diabetes should consume. Fiber should be recommended to clients to decrease constipation, which can be an effect of pregnancy. A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? 1 A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia X (§> B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer Vv ) C. Administer immune globulin to the client to prevent fetal isoimmunization __/ D. Administer intravenous antibiotics to prevent an infection Graded Response: Incorrect Correct Answer: C. Administer immune globulin to the client to prevent fetal isoimmunization Pel Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure. Incorrect Answers: A. The provider screens the client for chlamydia during a pelvic examination rather than through an amniocentesis. B. Testing the client's blood for Rh antibodies is done at the beginning of pregnancy and repeated at 28 weeks. This diagnostic test is performed on the client's blood rather than amniotic fluid. D. The provider performs the amniocentesis with sterile technique; although infection is a risk with any invasive procedure, the routine administration of prophylactic antibiotics is not indicated. A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? 7 ‘. _>3 A. Assess the client's reflexes v {_ B. Assess the newborn for respiratory depression X (@) c. Assess the client for bradycardia 3 ‘A D. Assess the newborn for signs of opiate withdrawal Graded Response: Incorrect Correct Answer: B. Assess the newborn for respiratory depression Peer Comparison A Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This 8 I_ medication crosses the placenta and causes respiratory depression in the newborn, which peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication. ec - 0 | Incorrect Answers: A. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses through stimulation of the mu and kappa opioid receptors. C. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status. D. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long period of time during pregnancy. A client receiving an opiate during labor would not lead to opiate dependence in the newborn. A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? Vv ' A. Nausea in the morning X @ B. Positive home pregnancy test ! C. Increased sensitivity of the cervix noted upon examination L _‘1 D. Gestational sac observed by transvaginal ultrasound Graded Response: Incorrect Correct Answer: A. Nausea in the morning Peer Compari: Nausea is a presumptive sign of pregnancy—that is, a subjective symptom reported by the mother that could have a cause other than pregnancy. Incorrect Answers: B. A home pregnancy test assesses for the presence of human chorionic gonadotrophin in the client's urine. This test is an objective finding, but a positive test could have other causes such as the presence of a hydatiform mole or certain cancers. Therefore, a positive home pregnancy test is considered a probable sign of pregnancy. C. An increase in sensitivity of the cervix and vagina is an objective finding noted by the examiner and a probable sign of pregnancy. D. Visualization of the gestational sac is a positive sign that can only be attributed to pregnancy. A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? (__) A. Blood pressure 90/52 mmHg v (_J B.Ketones 2+ __J C. Specific gravity 1.035 X @ . sodium 130 mEq/L Graded Response: Incorrect Correct Answer: B. Ketones 2+ The greatest risk to this client is malnutrition that poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately. Incorrect Answers: A. This blood pressure reading indicates hypotension, which might be caused by fluid-volume loss due to hyperemesis. However, another finding is the priority. C. This specific gravity indicates that the client's urine is concentrated and that the client is dehydrated. However, another finding is the priority. D. This sodium level indicates hyponatremia, a result of the electrolyte imbalances caused by hyperemesis. However, another finding is the priority. Peer Comparison ~ = [ i oo I A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take? X @) A. Prepare for emergency cesarean delivery B. Discontinue oxytocin infusion ! C. Position the parent to facilitate the McRoberts maneuver v __ D. Gather equipment for neonatal resuscitation Graded Response: Incorrect Correct Answer: D. Gather equipment for neonatal resuscitation Meconium-stained amniotic fluid can cause neonatal meconium aspiration syndrome. The nurse should gather equipment for neonatal resuscitation. Incorrect Answers: A. The presence of meconium-stained fluid is not an indication for cesarean delivery. Fetal indications for cesarean birth include an abnormal fetal heart rate pattern, malpresentation, maternal human immunodeficiency virus, active maternal herpes lesions, and congenital anomalies. B. Meconium-stained fluid does not require discontinuation of oxytocin. Oxytocin should be discontinued in the presence of late or variable fetal heart rate decelerations. C. The McRoberts maneuver is done to resolve a shoulder dystocia. It is not indicated in the presence of meconium-stained fluid. Peer Comparison o: | e | c| o [ A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? X @ A. A 1-week-old newborn who needs another phenylketonuria screening test Vi ) B. A4-day-old newborn who has an elevated bilirubin level and requires phototherapy ) C. A10-day-old newborn who is small for gestational age and requires daily weighing ) D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 |b) at discharge Graded Response: Incorrect Correct Answer: B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy Peer Comparison oA The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation 8 ._ posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which C I risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to D l initiate phototherapy immediately to help prevent this dangerous outcome. Incorrect Answers: A. Phenylketonuria is an inborn error of phenylalanine metabolism. Without treatment with a phenylalanine-free diet, newborns who have this disorder can develop severe, irreversible developmental delays. Blood collection for this test prior to 24 hours after delivery can resultin inconclusive results and the need for another specimen collection after at least 2 days of breast or formula feeding. The nurse should collect this specimen promptly; however, another client is the priority. C. D. The nurse should monitor this newborn’s weight to identify whether further intervention is needed to promote growth and development; however, another client is the priority. A nurse is caring for a client who is at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor? ) A. Contractions felt in the upper abdomen ! B. Asmall amount of bloody discharge X @ C. Contractions occurring every 2 to 10 min v {_ D. Changes in cervical dilation or effacement Graded Response: Incorrect Correct Answer: D. Changes in cervical dilation or effacement Peer Comparison Al Cervical changes are signs of true labor. 5 I Incorrect Answers: ®C I A. True labor contractions are typically felt in the lower back and radiate to the lower abdomen. D _ B. A small amount of bloody discharge can occur due to cervical trauma from intercourse or a vaginal exam. It does not indicate that the clientisin true labor. C. Irregular contractions are Braxton-Hicks contractions and are not a sign of true labor. A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? v |__ A. Turn the client onto her left side __ B. Palpate the client’s uterus x (@ c. Administer oxygen to the client __J D. Increase the client’s IV fluids Graded Response: Incorrect Correct Answer: A. Turn the client onto her left side Peer Comparison ~ I When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because 8 | they pose more of a threat to the client. The nurse should turn the client onto her left side since late decelerations indicate uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to ec . the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the D I fetal oxygen supply. The nurse might also need to use Maslow’s hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Incorrect Answers: B. The nurse should palpate the client’s uterus to assess for tachysystole. However, another action is the priority. C. The nurse should administer oxygen at 8 to 10 L/min by nonrebreather facemask to enhance placental perfusion. However, another action is the priority. D. The nurse should increase the client’s IV fluids to boost circulating fluid volume. However, another action is the priority.