ATI RN MATERNAL NEWBORN PROCTORED ACTUAL EXAM
AmnursemismassessingmamclientmwhomhasmgestationalmdiabetesmMellitusmandmismexperienci
ngmhyperglycemia.mwhichmofmthemfollowingmfindingsmshouldmthemnursemexpect?m-
m"ACCURATEmANSWER"mmreportsmincreasedmurinarymoutput.m
Increasedmurinarymoutput,mnauseamandmvomiting,mreportsmofmthirst,mabdominalmpain,mcons
tipation,mdrowsiness,mandmheadachesmaremmanifestationsmofmhyperglycemia.mOthermmanifes
tationsmincludemweakmrapidmpulse,mfruitymbreathmodor,murinempositivemformsugarmandmac
etone,mandmambloodmglucosemlevelmgreatermthanm200mmg/dL.
amnursemismcaringmformamclientmwhomism22mweeksmofmgestationmandmismHIVmpositive.m
whichmofmthemfollowingmactionsmshouldmthemnursemtake?m-
m"ACCURATEmANSWER"mmReportmthemclient'smconditionmtomthemlocalmhealthmdepartment.
Themnursemshouldmreportmthemconditionmtomthemlocalmhealthmdepartment.mHIVmismonemo
fmthemconditionsmonmthemlistmofmNationallymNotifiablemInfectiousmConditionsmthatmismrequ
iredmtombemreported.
amnursemismprovidingmteachingmformamclientmwhomhasmamnewmprescriptionmformcombined
moralmcontraceptives.mwhichmofmthemfollowingmfindingsmshouldmthemnursemincludemasman
madversemeffectmofmthismmedication?m-m"ACCURATEmANSWER"mmdepressionm
Themnursemshouldminstructmthemclientmthatmdepressionmismamcommonmadversemeffectmof
mcombinedmoralmcontraceptives.mOthermcommonmadversemeffectsmofmthemmedicationminclu
demamenorrhea,mweightmgain,mheadache,mnausea,mbreakthroughmbleeding,mandmbreastmten
derness.
amnursemismprovidingmteachingmtomamclientmwhomismatm40mweeksmofmgestationmandmhas
mamnewmprescriptionmformmisoprostol.mWhichmofmthemfollowingminstructionsmshouldmthem
nursemincludeminmthemteaching?m-
m"ACCURATEmANSWER"mm"Imcanmadministermoxytocinm4mhoursmaftermtheminsertionmofmth
emmedication."
Themnursemcanmadministermoxytocinmnomsoonermthanm4mhrmaftermthemlastmdosemofmmis
oprostol.mOxytocinmcanmbemadministeredmfollowingmmisoprostolmformclientsmwhomhavemcer
vicalmripeningmandmhavemnotmbegunmlabor.
amnursemismcaringmformamprenatalmclientmwhomhasmparvovirusmb19(fifthmdisease)mwhichm
ofmthemfollowingmactionsmshouldmthemnursemtake?m-
m"ACCURATEmANSWER"mmschedulemanmultrasoundmexaminationm
Themnursemshouldmschedulemserialmultrasoundmexaminationsmtommonitormthemfetusmduring
mthempregnancymtomdetectmthempossiblemdevelopmentmofmfetalmhydrops.mAlso,mthemvirus
mcanmcausemmiscarriage,mintrauterinemgrowthmrestriction,mfetalmanemia,mormstillbirth.
amnursemismpreparingmtomcollectmambloodmspecimenmfrommamnewbornmviamamheelmstick.
mwhichmofmthemfollowingmtechniquesmshouldmthemnursemusemtomhelpmminimizemthempain
mofmthemproceduremformthemnewborn?m-
m"ACCURATEmANSWER"mmplacemthemnewbornmskinmtomskinmonmthemmother'smchest.m
Placingmthemnewbornmskinmtomskinmonmthemmother'smchestmismanmeffectivemtechniquemto
msignificantlymdecreasemthemnewborn'smpainmlevelmandmanxiety.mThemnursemshouldmimple
mentmthismtechniquembefore,mduring,mandmaftermthemprocedure.
, amnursemismperformingmamvagmexaminationmonmamclientmwhomisminmlabormandmobserves
mthemumbilicalmcordmprotrudingmfrommthemvagina.maftermcallingmformassistance,mwhichmof
mthemfollowingmactionsmshouldmthemnursemtake?m-
m"ACCURATEmANSWER"mmInsertmtwomglovedmfingersmintomthemvaginamandmapplymupward
mpressuremtomthempresentingmpart.
Themnursemshouldmquicklymapplymglovesmandminsertmtwomfingersmintomthemvaginamtoward
mthemcervix,mexertingmupwardmpressuremontomthempresentingmpartmtomrelievemumbilicalmc
ordmcompressionmandmincreasemoxygenationmtomthemfetus.
amnursemismcaringmformamclientmwhomismatm24mweeksmofmgestationmandmhasmamsuspect
edmplacentalmabruption.mwhichmofmthemfollowingmlabmtestsmshouldmthemnursemexpectmthe
mprovidermtomprescribe?m-m"ACCURATEmANSWER"mmkleihauer-betkemtestm
ThemnursemshouldmexpectmthemprovidermtomprescribemamKleihauer-
Betkemtestmformamclientmwhomhasmsuspectedmplacentalmabruptionmtomdeterminemifmfetalm
bloodmisminmmaternalmcirculation.mThismtestmismusefulmtomdeterminemifmRho-
(D)mimmunemglobulinmtherapymshouldmbemadministeredmtomamclientmwhomismRh-negative.
amnursemismadmittingmamclientmwhomisminmlabor.mthemclientmadmitsmtomrecentmcocainem
use.mformwhichmofmthemfollowingmcomplicationsmshouldmthemnursemassess?m-
m"ACCURATEmANSWER"mmabruptiomplacentam
cocainemusemincreasesmthemriskmformvasoconstrictionmandmpossiblemabruptiomplacenta.
amnursemismassessingmamclientmwhomhasmseverempreeclampsia.mwhichmofmthemfollowingm
manifestationsmshouldmthemnursemexpect.m-m"ACCURATEmANSWER"mmblurredmvisionm
Themnursemshouldmidentifymthatmamclientmwhomhasmseverempreeclampsiamcanmhavemarteri
olarmvasospasmsmandmdecreasedmbloodmflowmtomthemretinamwhichmcanmleadmtomvisualmd
isturbances,msuchmasmblurredmvision,mdoublemvision,mormdarkmspotsminmthemvisualmfield.
amnursemismprovidingmeducationmaboutmfamilymbondingmtomparentsmwhomrecentlymadopte
dmamnewborn.mthemnursemshouldmmakemwhichmofmthemfollowingmsuggestionsmtomaidmthe
mfamily'sm7myrmoldmchildminmacceptingmthemnewmfamilymmember?m-
m"ACCURATEmANSWER"mmObtainmamgiftmfrommthemnewbornmtompresentmtomthemsibling.
Presentingmamgiftmfrommthemnewbornmtomthemsiblingmismamstrategymtomfacilitatemamscho
ol-
agemsibling'smacceptancemofmamnewmfamilymmember.mThismensuresmthatmthemsiblingmdoes
mnotmfeelmleftmoutmandmthatmtheymunderstandmtheirmroleminmthemfamily.
amnursemismassessingmamclientmwhomismreceivingmmorphinemviamivmbolusmformpainmfollow
ingmamCmsection.mthemnursemnotesmamrespmratemofm8mpermmin.mwhichmofmthemfollowin
gmmedicationsmshouldmthemnursemadminister?m-m"ACCURATEmANSWER"mmnaloxonem
Morphinemismamcommonmopioidmanalgesicmusedmformpostoperativempainmmanagementmthat
mcanmcausemcentralmnervousmsystemmdepressionmandmcanmcausemrespiratorymdepression.m
Themnursemshouldmadministermnaloxone,manmopioidmantagonist,mtomreversemthemopioid-
inducedmrespiratorymdepressionminmthemclient.
amnursemismteachingmamclientmwhomismatm10mweeksmofmgestationmaboutmnutritionmdurin
gmpregnancy.mwhichmofmthemfollowingmstatementsmbymthemclientmindicatesmanmunderstand
ingmofmthemteaching.m-
m"ACCURATEmANSWER"mm"Imshouldmtakem600mmicrogramsmofmfolicmacidmeachmday."
AmnursemismassessingmamclientmwhomhasmgestationalmdiabetesmMellitusmandmismexperienci
ngmhyperglycemia.mwhichmofmthemfollowingmfindingsmshouldmthemnursemexpect?m-
m"ACCURATEmANSWER"mmreportsmincreasedmurinarymoutput.m
Increasedmurinarymoutput,mnauseamandmvomiting,mreportsmofmthirst,mabdominalmpain,mcons
tipation,mdrowsiness,mandmheadachesmaremmanifestationsmofmhyperglycemia.mOthermmanifes
tationsmincludemweakmrapidmpulse,mfruitymbreathmodor,murinempositivemformsugarmandmac
etone,mandmambloodmglucosemlevelmgreatermthanm200mmg/dL.
amnursemismcaringmformamclientmwhomism22mweeksmofmgestationmandmismHIVmpositive.m
whichmofmthemfollowingmactionsmshouldmthemnursemtake?m-
m"ACCURATEmANSWER"mmReportmthemclient'smconditionmtomthemlocalmhealthmdepartment.
Themnursemshouldmreportmthemconditionmtomthemlocalmhealthmdepartment.mHIVmismonemo
fmthemconditionsmonmthemlistmofmNationallymNotifiablemInfectiousmConditionsmthatmismrequ
iredmtombemreported.
amnursemismprovidingmteachingmformamclientmwhomhasmamnewmprescriptionmformcombined
moralmcontraceptives.mwhichmofmthemfollowingmfindingsmshouldmthemnursemincludemasman
madversemeffectmofmthismmedication?m-m"ACCURATEmANSWER"mmdepressionm
Themnursemshouldminstructmthemclientmthatmdepressionmismamcommonmadversemeffectmof
mcombinedmoralmcontraceptives.mOthermcommonmadversemeffectsmofmthemmedicationminclu
demamenorrhea,mweightmgain,mheadache,mnausea,mbreakthroughmbleeding,mandmbreastmten
derness.
amnursemismprovidingmteachingmtomamclientmwhomismatm40mweeksmofmgestationmandmhas
mamnewmprescriptionmformmisoprostol.mWhichmofmthemfollowingminstructionsmshouldmthem
nursemincludeminmthemteaching?m-
m"ACCURATEmANSWER"mm"Imcanmadministermoxytocinm4mhoursmaftermtheminsertionmofmth
emmedication."
Themnursemcanmadministermoxytocinmnomsoonermthanm4mhrmaftermthemlastmdosemofmmis
oprostol.mOxytocinmcanmbemadministeredmfollowingmmisoprostolmformclientsmwhomhavemcer
vicalmripeningmandmhavemnotmbegunmlabor.
amnursemismcaringmformamprenatalmclientmwhomhasmparvovirusmb19(fifthmdisease)mwhichm
ofmthemfollowingmactionsmshouldmthemnursemtake?m-
m"ACCURATEmANSWER"mmschedulemanmultrasoundmexaminationm
Themnursemshouldmschedulemserialmultrasoundmexaminationsmtommonitormthemfetusmduring
mthempregnancymtomdetectmthempossiblemdevelopmentmofmfetalmhydrops.mAlso,mthemvirus
mcanmcausemmiscarriage,mintrauterinemgrowthmrestriction,mfetalmanemia,mormstillbirth.
amnursemismpreparingmtomcollectmambloodmspecimenmfrommamnewbornmviamamheelmstick.
mwhichmofmthemfollowingmtechniquesmshouldmthemnursemusemtomhelpmminimizemthempain
mofmthemproceduremformthemnewborn?m-
m"ACCURATEmANSWER"mmplacemthemnewbornmskinmtomskinmonmthemmother'smchest.m
Placingmthemnewbornmskinmtomskinmonmthemmother'smchestmismanmeffectivemtechniquemto
msignificantlymdecreasemthemnewborn'smpainmlevelmandmanxiety.mThemnursemshouldmimple
mentmthismtechniquembefore,mduring,mandmaftermthemprocedure.
, amnursemismperformingmamvagmexaminationmonmamclientmwhomisminmlabormandmobserves
mthemumbilicalmcordmprotrudingmfrommthemvagina.maftermcallingmformassistance,mwhichmof
mthemfollowingmactionsmshouldmthemnursemtake?m-
m"ACCURATEmANSWER"mmInsertmtwomglovedmfingersmintomthemvaginamandmapplymupward
mpressuremtomthempresentingmpart.
Themnursemshouldmquicklymapplymglovesmandminsertmtwomfingersmintomthemvaginamtoward
mthemcervix,mexertingmupwardmpressuremontomthempresentingmpartmtomrelievemumbilicalmc
ordmcompressionmandmincreasemoxygenationmtomthemfetus.
amnursemismcaringmformamclientmwhomismatm24mweeksmofmgestationmandmhasmamsuspect
edmplacentalmabruption.mwhichmofmthemfollowingmlabmtestsmshouldmthemnursemexpectmthe
mprovidermtomprescribe?m-m"ACCURATEmANSWER"mmkleihauer-betkemtestm
ThemnursemshouldmexpectmthemprovidermtomprescribemamKleihauer-
Betkemtestmformamclientmwhomhasmsuspectedmplacentalmabruptionmtomdeterminemifmfetalm
bloodmisminmmaternalmcirculation.mThismtestmismusefulmtomdeterminemifmRho-
(D)mimmunemglobulinmtherapymshouldmbemadministeredmtomamclientmwhomismRh-negative.
amnursemismadmittingmamclientmwhomisminmlabor.mthemclientmadmitsmtomrecentmcocainem
use.mformwhichmofmthemfollowingmcomplicationsmshouldmthemnursemassess?m-
m"ACCURATEmANSWER"mmabruptiomplacentam
cocainemusemincreasesmthemriskmformvasoconstrictionmandmpossiblemabruptiomplacenta.
amnursemismassessingmamclientmwhomhasmseverempreeclampsia.mwhichmofmthemfollowingm
manifestationsmshouldmthemnursemexpect.m-m"ACCURATEmANSWER"mmblurredmvisionm
Themnursemshouldmidentifymthatmamclientmwhomhasmseverempreeclampsiamcanmhavemarteri
olarmvasospasmsmandmdecreasedmbloodmflowmtomthemretinamwhichmcanmleadmtomvisualmd
isturbances,msuchmasmblurredmvision,mdoublemvision,mormdarkmspotsminmthemvisualmfield.
amnursemismprovidingmeducationmaboutmfamilymbondingmtomparentsmwhomrecentlymadopte
dmamnewborn.mthemnursemshouldmmakemwhichmofmthemfollowingmsuggestionsmtomaidmthe
mfamily'sm7myrmoldmchildminmacceptingmthemnewmfamilymmember?m-
m"ACCURATEmANSWER"mmObtainmamgiftmfrommthemnewbornmtompresentmtomthemsibling.
Presentingmamgiftmfrommthemnewbornmtomthemsiblingmismamstrategymtomfacilitatemamscho
ol-
agemsibling'smacceptancemofmamnewmfamilymmember.mThismensuresmthatmthemsiblingmdoes
mnotmfeelmleftmoutmandmthatmtheymunderstandmtheirmroleminmthemfamily.
amnursemismassessingmamclientmwhomismreceivingmmorphinemviamivmbolusmformpainmfollow
ingmamCmsection.mthemnursemnotesmamrespmratemofm8mpermmin.mwhichmofmthemfollowin
gmmedicationsmshouldmthemnursemadminister?m-m"ACCURATEmANSWER"mmnaloxonem
Morphinemismamcommonmopioidmanalgesicmusedmformpostoperativempainmmanagementmthat
mcanmcausemcentralmnervousmsystemmdepressionmandmcanmcausemrespiratorymdepression.m
Themnursemshouldmadministermnaloxone,manmopioidmantagonist,mtomreversemthemopioid-
inducedmrespiratorymdepressionminmthemclient.
amnursemismteachingmamclientmwhomismatm10mweeksmofmgestationmaboutmnutritionmdurin
gmpregnancy.mwhichmofmthemfollowingmstatementsmbymthemclientmindicatesmanmunderstand
ingmofmthemteaching.m-
m"ACCURATEmANSWER"mm"Imshouldmtakem600mmicrogramsmofmfolicmacidmeachmday."
