VATI Maternal Newborn Pre-Assessment Questions with correct answers
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?
A. Rupture of the membranes
B. Changes in the cervix
C. Station of the presenting part
D. Pattern of contractions Correct Answer - B. Changes in the cervix
Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)
A. "I'll expect the plastic ring to fall off by itself within a week."
B. "I'll apply petroleum jelly to his penis with diaper changes."
C. "I'll wash his penis with warm water and mild soap each day."
D. "I'll call the doctor if I see any bleeding."
E. "I'll make sure his diaper is loose in the front." Correct Answer - A. "I'll expect the plastic ring to fall off by itself within a week."
D. "I'll call the doctor if I see any bleeding."
E. "I'll make sure his diaper is loose in the front." A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?
A. Contractions lasting longer than 90 seconds
B. Contractions occurring every 3 to 5 min
C. Contractions are strong in intensity
D. Client reports feeling contractions in lower back Correct Answer - A. Contractions lasting longer than 90 seconds
A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.
In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min intervals. This is an expected finding. This is an expected finding in a client who is moving from the active to transition phase of the first stage of labor. It does not need to be reported to the provider. This is an expected finding in a client who is in true labor. As the labor progresses, the contractions radiate to the abdomen.
A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreaths above the umbilicus. Which of the following actions should the nurse
complete at this time?
A. Massage the fundus
B. Insert a urinary catheter
C. Have the client urinate
D. Administer an analgesic Correct Answer - C. Have the client urinate A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus.
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?
A. "It is used to stop preterm labor contractions."
B. "It halts cervical dilation."
C. "It promotes fetal lung maturity."
D. "It increases the fetal heart rate." Correct Answer - C. "It promotes fetal lung maturity."
Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant.
Magnesium sulfate, not betamethasone, is an example of a tocolytic medication that helps stop preterm labor. A tocolytic medication relaxes the smooth muscles of
the uterus to stop preterm labor, and if effective, will also halt cervical dilation. Terbutaline is an example of a tocolytic medication that can cause fetal tachycardia.
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
A. "Preterm newborns have a smaller body surface area than normal newborns."
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?
A. Rupture of the membranes
B. Changes in the cervix
C. Station of the presenting part
D. Pattern of contractions Correct Answer - B. Changes in the cervix
Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)
A. "I'll expect the plastic ring to fall off by itself within a week."
B. "I'll apply petroleum jelly to his penis with diaper changes."
C. "I'll wash his penis with warm water and mild soap each day."
D. "I'll call the doctor if I see any bleeding."
E. "I'll make sure his diaper is loose in the front." Correct Answer - A. "I'll expect the plastic ring to fall off by itself within a week."
D. "I'll call the doctor if I see any bleeding."
E. "I'll make sure his diaper is loose in the front." A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?
A. Contractions lasting longer than 90 seconds
B. Contractions occurring every 3 to 5 min
C. Contractions are strong in intensity
D. Client reports feeling contractions in lower back Correct Answer - A. Contractions lasting longer than 90 seconds
A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.
In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min intervals. This is an expected finding. This is an expected finding in a client who is moving from the active to transition phase of the first stage of labor. It does not need to be reported to the provider. This is an expected finding in a client who is in true labor. As the labor progresses, the contractions radiate to the abdomen.
A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreaths above the umbilicus. Which of the following actions should the nurse
complete at this time?
A. Massage the fundus
B. Insert a urinary catheter
C. Have the client urinate
D. Administer an analgesic Correct Answer - C. Have the client urinate A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus.
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?
A. "It is used to stop preterm labor contractions."
B. "It halts cervical dilation."
C. "It promotes fetal lung maturity."
D. "It increases the fetal heart rate." Correct Answer - C. "It promotes fetal lung maturity."
Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant.
Magnesium sulfate, not betamethasone, is an example of a tocolytic medication that helps stop preterm labor. A tocolytic medication relaxes the smooth muscles of
the uterus to stop preterm labor, and if effective, will also halt cervical dilation. Terbutaline is an example of a tocolytic medication that can cause fetal tachycardia.
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
A. "Preterm newborns have a smaller body surface area than normal newborns."
