ATI RN Maternal Newborn Proctored Exam |
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Performance
A nurse is providing discharge teaching to a client who is postpartum. For which of the
following manifestations should the nurse instruct the client to monitor and report to the
provider? - -CORRECT ANS- -A. Persistent abdominal striae
B. Temperature 37.8° C (100° F)
C. Unilateral breast pain
C. Brownish-red discharge on day 5
Answer: Unilateral breast pain
A. Persistent abdominal striae
Persistent abdominal striae are caused by the separation of the underlying connective
tissue and are an expected postpartum finding.
B. Temperature 37.8° C (100° F)
The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher
because it could be an indication of infection.
C. Unilateral breast pain
Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain
can be indications of mastitis, an infection of the breast tissue. The nurse should instruct
the client to report this manifestation to the provider.
C. Brownish-red discharge on day 5
,Brownish-red discharge is an expected manifestation during days 3 to 10. The client should
report a large amount of lochia and large clots to the provider.
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation.
Based on the chart findings and documentation, the nursing plan of care should include
which of the following actions?
Exhibit 1: Diagnostic Results
Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-
negative
Exhibit 2: Medication Administration Record
Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM
onceNalbuphine 10 mg IV every 3 hr PRN pain
Exhibit 3: Progress Report
1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 -
Fetal heart rate 130/min with moderate variabilityUterine contractions q 5 to 8 min lasting
30 to 60 sec durationUterine contractions palpated at 1+ intensityClient reports uterine
contraction pain of 2 on a scale of 0 to 10 - -CORRECT ANS- -A. Administer terbutaline.
B. Discuss possible genetic anomalies with the client.
C. Administer nalbuphine.
D. Discontinue external fetal monitoring.
Answer: Administer terbutaline.
, A. Administer terbutaline.
The nurse should administer terbutaline to stop contractions because the laboratory
results indicate that the fetus's lungs are not mature enough for birth.
B. Discuss possible genetic anomalies with the client.
There is no indication of genetic anomalies based on the results of the amniocentesis.
C. Administer nalbuphine.
Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to
10 is mild pain.
D. Discontinue external fetal monitoring.
The nurse should not discontinue external fetal monitoring. Because the client is exhibiting
manifestations of preterm labor, fetal well-being and contraction patterns should be
continuously monitored to continue to assess for preterm labor and provide necessary
interventions to stop contractions.
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following
findings should the nurse report to the provider? - -CORRECT ANS- -A. Bilirubin 9 mg/dL
B. Hemoglobin 18 g/dL
C. Platelets 175,0000/mm3
D. Hematocrit 45%
Answer: Bilirubin 9 mg/dL
A. Bilirubin 9 mg/dL
Guaranteed Success with Verified Solutions for Top
Performance
A nurse is providing discharge teaching to a client who is postpartum. For which of the
following manifestations should the nurse instruct the client to monitor and report to the
provider? - -CORRECT ANS- -A. Persistent abdominal striae
B. Temperature 37.8° C (100° F)
C. Unilateral breast pain
C. Brownish-red discharge on day 5
Answer: Unilateral breast pain
A. Persistent abdominal striae
Persistent abdominal striae are caused by the separation of the underlying connective
tissue and are an expected postpartum finding.
B. Temperature 37.8° C (100° F)
The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher
because it could be an indication of infection.
C. Unilateral breast pain
Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain
can be indications of mastitis, an infection of the breast tissue. The nurse should instruct
the client to report this manifestation to the provider.
C. Brownish-red discharge on day 5
,Brownish-red discharge is an expected manifestation during days 3 to 10. The client should
report a large amount of lochia and large clots to the provider.
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation.
Based on the chart findings and documentation, the nursing plan of care should include
which of the following actions?
Exhibit 1: Diagnostic Results
Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-
negative
Exhibit 2: Medication Administration Record
Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM
onceNalbuphine 10 mg IV every 3 hr PRN pain
Exhibit 3: Progress Report
1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 -
Fetal heart rate 130/min with moderate variabilityUterine contractions q 5 to 8 min lasting
30 to 60 sec durationUterine contractions palpated at 1+ intensityClient reports uterine
contraction pain of 2 on a scale of 0 to 10 - -CORRECT ANS- -A. Administer terbutaline.
B. Discuss possible genetic anomalies with the client.
C. Administer nalbuphine.
D. Discontinue external fetal monitoring.
Answer: Administer terbutaline.
, A. Administer terbutaline.
The nurse should administer terbutaline to stop contractions because the laboratory
results indicate that the fetus's lungs are not mature enough for birth.
B. Discuss possible genetic anomalies with the client.
There is no indication of genetic anomalies based on the results of the amniocentesis.
C. Administer nalbuphine.
Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to
10 is mild pain.
D. Discontinue external fetal monitoring.
The nurse should not discontinue external fetal monitoring. Because the client is exhibiting
manifestations of preterm labor, fetal well-being and contraction patterns should be
continuously monitored to continue to assess for preterm labor and provide necessary
interventions to stop contractions.
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following
findings should the nurse report to the provider? - -CORRECT ANS- -A. Bilirubin 9 mg/dL
B. Hemoglobin 18 g/dL
C. Platelets 175,0000/mm3
D. Hematocrit 45%
Answer: Bilirubin 9 mg/dL
A. Bilirubin 9 mg/dL
