RN ATI MATERNAL NEWBORN PROCTORED EXAM (VERSION 19) - 2017 RN ATI Capstone Content Review Thompson_P_2

1. normal assessment finding of full-term newborn 1 hr after vaginal delivery: HEAD CIRCUMFERENCE IS GREATER THAN THE CHEST CIRCUMFERENCE p.268ati 2. look over SIDS: need for additional teaching 3. which answer choice indicates that a new mother is having difficulty adjusting to her role as a new mother 4. for a female who is bottle-feeding her newborn, what should the nurse do if the female's breast are warm & firm (I chose to teach the client to apply cold compresses). since the pt is bottle-feeding, there is no need to pump the breast because pumping will stimulate more milk to be made. The client with warm and firm breasts have breast engorgement...cold compresses are used for breast engorgement. Pg 223ati 5. which statement by the client in post-term labor should the nurse give the highest priority? (a) i have not felt my baby move as much today (b) i feel like i cannot breathe when i walk up the stairs (c) i saw a blood-streaked discharge a few hours ago (d) when my water broke, it was not clear my guess b/c amniotic fluid should be clear pg.185ati 6. assessment finding for placenta previa (painless vaginal bleeding) pg. 71ati 7. a client who is pregnant w/ twins is undergoing an amniocentesis. the nurse knows that the client's elevated level of alpha fetoprotein most likely indicates:(a) a multifetal pregnancy (b) overestimation of gestation calculation (c) Rh incompatibility (d) fetal lung maturity pg.689text 8. highest priority for an adolescent who comes to the prenatal clinic: (a) socioeconomic status (b) psychological readiness (c) partner support (d) nutritional status (my guess) 9. A client is having back labor but is uncomfortable and wants a natural delivery; nursing intervention: ( i think i chose to assist the client to a hands-and-knees position); one of the other choices was offer a whirlpool bath SACRAL COUNTERPRESSUREHEAT/COLD THERAPY, HYDROTHERAPY(WHIRLPOOL),ACUPRESSURE pg.133ati 10. 13 weeks pregnant w/ hyperemesis gravidarum (vomiting/morning sickness). which assessment finding concerns the nurse (KETONURIA//KETONES OF 2+) pg.94 ati, 704 text 11. A client who is at 40 weeks of gestation is admitted to the labor and delivery unit with her cervix dilated 1 cm and 50% effaced(thinning of the cervix). Two hours after receiving secobarbital (Seconal) 200 mg PO, the client wakes up and delivery is imminent. which of the following actions should the nurse take first? (1) place a bulb syringe in the radiant warmer (2) have naloxone (narcan) available for the newborn (3)obtain warm blankets to place around the newborn (4) test the function of the bag-valve mask pg. 159ati 12. which choice should the nurse instruct the client to contact the primary care provider (the nurse is providing discharge teaching): THE INFANT HAS LESS THAN 6 WET DIAPERS IN 24 HOURS pg.309ati 13. initial physical assessment on a newborn; which answer choice requires further evaluation by the nurse: (1)bluish coloring of the feet (2)small, pin-pointed, reddish-blue spots on the chest (3)gray-white cheesy substance covering the skin (4)overlapping suture lines (overlapping suture lines is a normal finding due to the molding of the head as the infant goes through the birth canal. acrocyanosis is also a normal finding. vernix is a normal finding) pg.270ati 14. select all that apply: which assessment findings indicates that a newborn is experiencing HYPOglycemia: jitterness, poor feeding, weak shrill cry, irregular respirations, cyanosis, apnea, lethargy, diaphoresis,flaccid muscle tone, seizures/coma, glucose <40 pg. 318ati 15. what should the nurse instruct a client who is 34 weeks to report immediately (urinary frequency; ankle edema; persistent headache; increased leukorrhea)pg. 354text 16. KNOW GTPAL pg.25ati 17. nonpharmacological pain management for the client who had an episiotomy in the 4th stage of labor (look over ice packs and warm sitz baths) others include squeeze bottle, topical anesthetic cream/spray, side lying pg.492, 495text 18. for a client receiving oxytocin (pitocin), the fetal monitor shows a series of late decelerations. Which action should the nurse take first: (1) stop the oxytocin infusion (2) notify provider (3) position pt on her left side (4) administer oxygen via face mask pg.149ati 19. which client should be assessed 1st...(I chose the client who had the burning w/ frequent urination for 5 days...the other choices indicated normal pregnancy findings. This one indicates that the pt has a UTI) 20. preeclampsia...which finding requires intervention (1) Hgb of 14.8 (2) platelet count 60,000 (3) serum creatinine 0.8 (4) urine protein concentration 200mg/24 hour  platelet count should be 150,000-450,000….Proteinuria is defined as a concentration at or greater than 300mg/24hr pg. 661text, 100ati 21. One hour after delivery, a client who is receiving IV oxytocin (Pitocin) starts passing moderate-sized clots. Vital signs reveal an increase in pulse rate and a decrease in blood pressure. after massaging the fundus, the nurse should first (1) give lactated ringer's IV bolus (2) administer methlergonovine (Methergine) (3)assist the client to a side-lying position (4)insert an indwelling urinary catheterThe findings indicate that the client is going into shock from losing too much blood...management of shock includes administration of IV fluids to replace what is lost] pg.237ati 22. for a breastfeeding pt w/ breast pain and fever, what should the consultant determine 1st to evaluate the client's condition (1) if the pt is using analgesics for breast pain (2)review the pt's latch on technique (3)question the pt if she has areas of redness on the breast (4) ask the pt if she is pumping her breasts look over mastitis pg. 252ati, 629text 23. a nurse is caring for a client at 24 weeks of gestation whose glucose screening test result is at 150. which of the following nursing actions is appropriate? (1) perform a urine screen for ketones (2) schedule the pt for an oral glucose tolerance test (3)determine if the client has fasted (4)repeat the glucose screening test to verify results (THE NURSE SHOULD ALWAYS ASSESS 1ST. I THINK I CHOSE TO DETERMINE IF THE PT HAS FASTED. IF THE PT HAD SOMETHING TO EAT, THIS COULD CAUSE THE READING TO BE ELEVATED) 24. know what to tell a pt who says that they are having contractions. what should the nurse tell the client to do after she has told the pt to empty her bladder and drink 32oz of water 25. need for additional teaching: "I CAN APPLY A HEATING PAD DIRECTLY TO MY SKIN TO RELIEVE BACK PAIN"; heat and ice applications should never be directly applied to the skin pg. 396text 26. a nurse is caring for a client who is in labor and has no knowledge of nonpharmacological comfort measures. which of the following nursing interventions is appropriate for this client? (1) hypnosis (2)slow-paced breathing (3)controlled relaxation techniques (4)biofeedback pg.390text 27. contraindication to IUD insertion (1) history of pelvic inflammatory disease (2)delivery of a preterm newborn (3)history of pregnancy-induced hypertension (4)desire to have a child within 3 years pg.10ati 28. what should the nurse do 1st when caring for a pt following a tonic-clonic seizure (1) insert catheter (2) give O2 (3)administer mag sulfate (4)assess bp pg. 667text 29. which order should the nurse question regarding a client with a warm, red area in the right lower extremity (the question indicates that the patient has deep vein thrombosis): answer choices include applying ice packs to area; give an NSAID; place pt on bedrest with leg elevated, and initiate continuous IV heparin) which would the nurse question. Pg.231ati 30. what should the nurse do for a client complaining of a pounding headache who is receiving IV insulin for type 1 diabetes w/ a glucose level of 160. (1)increase rate of IV insulin infusion (2)give 15g of carbs -->THIS IS FOR HYPOGLYCEMIC (3)recheck the blood glucose in 4 hours (4)administer pain medication pg.699text 31. know about RhoGAM (remember, RhoGAM is administered to Rh (-) women who have Rh (+) fetus…it is also given after invasive procedures, miscarriage/abortion pg. 871text, 57ati 32. highest priority outcome for a pregnant woman with pre-eclampsia (hypoactive reflexes, seizure prevention(my guess); term delivery; or fluid balance) 33. potential complication of amniocentesis pg. 57 ati