ATI PN MATERNAL NEWBORN PROCTORED
EXAM
20. A nurse is preparing to administer oxytocin to a client who is postpartum.
Which of the following findings is an indication for the administration of the
medication? (Select all that apply.)
Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.
Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing
vaginal
bleedin
g.
21. A nurse is caring for a full-term newborn immediately following birth. Which of
the following actions should the nurse take first?
Dry the newborn
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take
immediately after delivery is to dry the newborn.
22. A nurse is performing a physical assessment of a newborn. Which of the
following clinical findings should the nurse expect? (Select all that apply.)
A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is
from 110/min to 160/min while awake.
A respiratory rate of 58/min is correct. The expected reference range for a newborn's
respiratory rate is from 30/min to 60/min.
A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's
weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb).
23. A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings should
the nurse report to the provider? (Click on the "Exhibit" button for additional information
about the client. There are three tabs that contain separate categories of data.)
Progress Notes
Fundal height 30 cm
Good fetal movement
Not experiencing headache, dizziness, blurred vision, or vaginal bleeding
Fetal heart rate 110/min
Fundal height measurement
A fundal height measurement of 30 cm should be reported to the provider. Fundal height
should be measured in centimeters and is the same as the number of gestational weeks plus or
minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding
, to the provider.
24. A nurse is performing a routine assessment on a client who is at 18 weeks of
gestation. Which of the following findings should the nurse expect?
The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in
gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this
is an expected finding by the nurse.
25. A nurse is teaching a client about Rho(D) immune globulin. Which of the
following statements by the client indicates an understanding of the teaching?
“I will need this medication if I have an amniocentesis.”
Rho(D) immune globulin is given following an amniocentesis because of the potential of
fetal RBCs entering the maternal circulation.
26. A nurse is caring for a client who is anemic at 32 weeks of gestation and is in
preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the
following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn.
Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and
prevent respiratory distress.
27. A nurse is teaching a client who is at 8 weeks of gestation about exercise.
Which of the following instructions should the nurse include in the teaching?
“You should exercise for 30 minutes each day.”
The nurse should instruct the client to engage in 30 min of moderate exercise every day
to improve muscle tone throughout her pregnancy.
28. A nurse is assessing a newborn 12 hr after birth. Which of the following
manifestations should the nurse report to the provider?
Jaundice
Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility,
hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the
provider.
29. A nurse is planning care for a client who is to undergo a nonstress test. Which of
the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected. Fetal
movement may not be evident on the fetal monitor and tracing. Instructing the client to
press the button when she detects fetal movement will ensure that the fetal movement is
noted.
EXAM
20. A nurse is preparing to administer oxytocin to a client who is postpartum.
Which of the following findings is an indication for the administration of the
medication? (Select all that apply.)
Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.
Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing
vaginal
bleedin
g.
21. A nurse is caring for a full-term newborn immediately following birth. Which of
the following actions should the nurse take first?
Dry the newborn
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take
immediately after delivery is to dry the newborn.
22. A nurse is performing a physical assessment of a newborn. Which of the
following clinical findings should the nurse expect? (Select all that apply.)
A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is
from 110/min to 160/min while awake.
A respiratory rate of 58/min is correct. The expected reference range for a newborn's
respiratory rate is from 30/min to 60/min.
A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's
weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb).
23. A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings should
the nurse report to the provider? (Click on the "Exhibit" button for additional information
about the client. There are three tabs that contain separate categories of data.)
Progress Notes
Fundal height 30 cm
Good fetal movement
Not experiencing headache, dizziness, blurred vision, or vaginal bleeding
Fetal heart rate 110/min
Fundal height measurement
A fundal height measurement of 30 cm should be reported to the provider. Fundal height
should be measured in centimeters and is the same as the number of gestational weeks plus or
minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding
, to the provider.
24. A nurse is performing a routine assessment on a client who is at 18 weeks of
gestation. Which of the following findings should the nurse expect?
The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in
gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this
is an expected finding by the nurse.
25. A nurse is teaching a client about Rho(D) immune globulin. Which of the
following statements by the client indicates an understanding of the teaching?
“I will need this medication if I have an amniocentesis.”
Rho(D) immune globulin is given following an amniocentesis because of the potential of
fetal RBCs entering the maternal circulation.
26. A nurse is caring for a client who is anemic at 32 weeks of gestation and is in
preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the
following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn.
Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and
prevent respiratory distress.
27. A nurse is teaching a client who is at 8 weeks of gestation about exercise.
Which of the following instructions should the nurse include in the teaching?
“You should exercise for 30 minutes each day.”
The nurse should instruct the client to engage in 30 min of moderate exercise every day
to improve muscle tone throughout her pregnancy.
28. A nurse is assessing a newborn 12 hr after birth. Which of the following
manifestations should the nurse report to the provider?
Jaundice
Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility,
hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the
provider.
29. A nurse is planning care for a client who is to undergo a nonstress test. Which of
the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected. Fetal
movement may not be evident on the fetal monitor and tracing. Instructing the client to
press the button when she detects fetal movement will ensure that the fetal movement is
noted.
