MATERNAL NEWBORN ATI PROCTORED
EXAM FULL ANSWERS QUESTIONS
AND COMPLETE SOLUTIONS A+
GRADE 2024
A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
labor. What meds should the nurse plan to administer? - ANS-betamethasone
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
and asks the nurse how the provider will confirm her pregnancy. The nurse should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
inform the client that what lab test will be used to confirm her pregnancy? - ANS-
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
urine test for presence of HCG
,m ,m ,m ,m ,m
A nurse is caring for a client who believes she may be pregnant. What finding should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the nurse identify as a positive sign of pregnancy?
,m ,m ,m ,m ,m ,m ,m ,m ,m
a. palpable fetal movement - ANS-palpable fetal movement
,m ,m ,m ,m ,m ,m ,m
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the nurse expect? - ANS-renal agenesis
,m ,m ,m ,m ,m ,m
A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
fracture due to blunt abd trauma. What findings should the nurse expect? - ANS-
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
uterine contractions ,m
The nurse should expect the client to be experiencing uterine contractions due to
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
abdominal trauma.
,m ,m
A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
What findings should the nurse expect? - ANS-dark brown vaginal discharge
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
chorionic villi, which gives rise to multiple cysts. The products of conception transform
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
HTN. What finding should the nurse identify as the priority? - ANS-480 mL urine
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
output in 24 hrs
,m ,m ,m ,m
,When using the urgent vs. nonurgent approach to client care, the nurse should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
determine that the priority finding is 480 mL of urine output in 24 hr because the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
progression of preeclampsia to preeclampsia with severe features, which requires
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
immediate intervention. Therefore, this is the priority finding.
,m ,m ,m ,m ,m ,m ,m ,m
A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
should the nurse include in the teaching? - ANS-you should continue to take
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
zidovudine throughout the pregnancy
,m ,m ,m ,m
-can be transmitted through breastfeeding
,m ,m ,m ,m
-she can continue to have sex
,m ,m ,m ,m ,m
The nurse should inform the client that taking prescription antiviral medication every
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
day decreases the risk of transmission of HIV to her newborn.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is providing teaching to a client who is at 8 wks gestation about
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
manifestations to report to the provider during pregnancy. What info should the nurse
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
include in the teaching? - ANS-blurred or double vision
,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is caring for a client who is in the latent phase of labor and is receiving
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
oxytocin via continuous IV infusion. The nurse notes that the client is having
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
contractions every 2 min which last 100-110 seconds that the fetal heart rate is
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
reassuring. What action should the nurse take? - ANS-decrease the dose of oxytocin
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
by half
,m ,m
The nurse should decrease the dose of oxytocin by half because the client is
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
experiencing uterine tachysystole.
,m ,m ,m
A nurse is caring for a client who is in active labor and has meconium staining of the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
monitor. What action should the nurse take? - ANS-prepare equipment needed for
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
newborn resuscitation
,m ,m
The nurse should ensure that all supplies and equipment needed for resuscitation of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the newborn are readily available for every delivery. Endotracheal suctioning is
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
recommended in cases of meconium staining only if the newborn has poor
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
respiratory effort, decreased muscle tone, and bradycardia after delivery.
,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is reviewing the medical record of a client who is at 33 wks gestation and has
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
placenta previa and bleeding. What scripts should the nurse clarify with the provider?
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
- ANS-perform a vaginal exam
,m ,m ,m ,m ,m
When a client has a placenta previa, the placenta implants in the lower part of the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
uterus and obstructs the cervical os (the opening to the vagina). The nurse should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
,,m clarify this prescription because any manipulation can cause tearing of the placenta
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
,m and increased bleeding.
,m ,m
A nurse is caring for a client who is at 37 wks gestation and is undergoing a
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
nonstress test. The FHR is 130 without accelerations for the past 10 min. What
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
action should the nurse take? - ANS-use vibroacoustic stim on the client's abd for 3
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
seconds
,m
The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
activity because the fetus is most likely sleeping. Fetal movement should cause
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
accelerations in the FHR.
,m ,m ,m ,m
A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
notes that the client is rubella non-immune, positive for group A beta-hemolytic strep,
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
and has a blood type O neg. What action should the nurse take? - ANS-instruct the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
client to obtain a rubella immunization after delivery
,m ,m ,m ,m ,m ,m ,m ,m
A nurse is reviewing the med record of a client who is at 39 wks gestation and has
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
polyhydramnios. What finding should the nurse expect? - ANS-fetal GI anomaly
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
fetus. Gastrointestinal malformations and neurologic disorders are expected findings
,m ,m ,m ,m ,m ,m ,m ,m ,m
for a fetus experiencing the effects of polyhydramnios.
,m ,m ,m ,m ,m ,m ,m ,m
A nurse is caring for a client who is in the latent phase of labor and is experiencing
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
low back pain. What action should the nurse take? - ANS-apply pressure to the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
client's sacral area during contractions
,m ,m ,m ,m ,m
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
sulfate via continuous IV infusion about expected adverse effects. What adverse
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
effects should the nurse include in the teaching? - ANS-feeling of warmth
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
The nurse should tell the client to expect the feeling of warmth all over her body while
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the magnesium sulfate is infusing.
,m ,m ,m ,m ,m
A nurse is teaching a client who is at 12 wks gestation about manifestations of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
potential complications that she should report to her provider. What info should the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
nurse include in the teaching? - ANS-swelling of the face
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the first trimester. What info should the nurse include in the teaching? - ANS-you will
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
need to have a full bladder during the ultrasound
,m ,m ,m ,m ,m ,m ,m ,m ,m
MY ANSWER ,m
, The nurse should tell the client that a full bladder helps to lift the gravid uterus out of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the pelvis during the examination. Therefore, it is important to ensure that the client
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
has a full bladder to obtain the most accurate image of the fetus.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is assessing a client who is 34 wks gestation and has mild placental
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
abruption. What finding should the nurse expect? - ANS-dark red vaginal bleeding
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
The nurse should expect the client who has a mild placental abruption to have
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
minimal dark red vaginal bleeding.
,m ,m ,m ,m ,m
A nurse is caring for a client whose last menstrual period began july 8. Using Nageles
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
rule, the nurse should identify the client's estimated DOB as what? - ANS-. april 15
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is caring for a client who is at 39 wks gestation and is in the active phase of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
labor. The nurse observes late decels in the FHR. What finding should the nurse
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
identify as the cause of late decels? - ANS-uteroplacental insufficiency
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
nurse report to the provider? - ANS-urinary output 20 mL/hr
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
The nurse should report a urinary output of 20 mL/hr because this can indicate
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
decrease in urinary output can also indicate a decrease in renal perfusion secondary
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
to a worsening of the client's pre-eclampsia.
,m ,m ,m ,m ,m ,m ,m
A nurse is teaching a client who is at 13 wks gestation about the treatment of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
incompetent cervix with cervical cerclage. What statement by the client indicates an
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
understanding of teaching? - ANS-I should go to the hospital if I think I may be in
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
labor
,m
Cervical cerclage prevents premature opening of the cervix during pregnancy. The
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
client should immediately go to a facility for evaluation if she experiences any
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
manifestations of labor while the cerclage is in place. If the client experiences
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
preterm uterine contractions she might require tocolytic therapy.
,m ,m ,m ,m ,m ,m ,m ,m
A nurse is admitting a client who is in labor and experiencing moderate bright red
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
vaginal bleeding. What action should the nurse take? - ANS-obtain blood samples for
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
baseline lab values
,m ,m ,m
The nurse should obtain samples of the client's blood for baseline testing of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
hemoglobin and hematocrit levels.
,m ,m ,m ,m
A nurse is caring for a client who is at 38 wks of gestation and reports no fetal
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
movement for 24 hr. What action should the nurse take? - ANS-auscultate for a FHR
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
EXAM FULL ANSWERS QUESTIONS
AND COMPLETE SOLUTIONS A+
GRADE 2024
A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
labor. What meds should the nurse plan to administer? - ANS-betamethasone
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
and asks the nurse how the provider will confirm her pregnancy. The nurse should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
inform the client that what lab test will be used to confirm her pregnancy? - ANS-
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
urine test for presence of HCG
,m ,m ,m ,m ,m
A nurse is caring for a client who believes she may be pregnant. What finding should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the nurse identify as a positive sign of pregnancy?
,m ,m ,m ,m ,m ,m ,m ,m ,m
a. palpable fetal movement - ANS-palpable fetal movement
,m ,m ,m ,m ,m ,m ,m
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the nurse expect? - ANS-renal agenesis
,m ,m ,m ,m ,m ,m
A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
fracture due to blunt abd trauma. What findings should the nurse expect? - ANS-
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
uterine contractions ,m
The nurse should expect the client to be experiencing uterine contractions due to
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
abdominal trauma.
,m ,m
A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
What findings should the nurse expect? - ANS-dark brown vaginal discharge
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
chorionic villi, which gives rise to multiple cysts. The products of conception transform
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
HTN. What finding should the nurse identify as the priority? - ANS-480 mL urine
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
output in 24 hrs
,m ,m ,m ,m
,When using the urgent vs. nonurgent approach to client care, the nurse should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
determine that the priority finding is 480 mL of urine output in 24 hr because the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
progression of preeclampsia to preeclampsia with severe features, which requires
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
immediate intervention. Therefore, this is the priority finding.
,m ,m ,m ,m ,m ,m ,m ,m
A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
should the nurse include in the teaching? - ANS-you should continue to take
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
zidovudine throughout the pregnancy
,m ,m ,m ,m
-can be transmitted through breastfeeding
,m ,m ,m ,m
-she can continue to have sex
,m ,m ,m ,m ,m
The nurse should inform the client that taking prescription antiviral medication every
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
day decreases the risk of transmission of HIV to her newborn.
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is providing teaching to a client who is at 8 wks gestation about
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
manifestations to report to the provider during pregnancy. What info should the nurse
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
include in the teaching? - ANS-blurred or double vision
,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is caring for a client who is in the latent phase of labor and is receiving
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
oxytocin via continuous IV infusion. The nurse notes that the client is having
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
contractions every 2 min which last 100-110 seconds that the fetal heart rate is
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
reassuring. What action should the nurse take? - ANS-decrease the dose of oxytocin
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
by half
,m ,m
The nurse should decrease the dose of oxytocin by half because the client is
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
experiencing uterine tachysystole.
,m ,m ,m
A nurse is caring for a client who is in active labor and has meconium staining of the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
monitor. What action should the nurse take? - ANS-prepare equipment needed for
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
newborn resuscitation
,m ,m
The nurse should ensure that all supplies and equipment needed for resuscitation of
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
the newborn are readily available for every delivery. Endotracheal suctioning is
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
recommended in cases of meconium staining only if the newborn has poor
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
respiratory effort, decreased muscle tone, and bradycardia after delivery.
,m ,m ,m ,m ,m ,m ,m ,m ,m
A nurse is reviewing the medical record of a client who is at 33 wks gestation and has
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
placenta previa and bleeding. What scripts should the nurse clarify with the provider?
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
- ANS-perform a vaginal exam
,m ,m ,m ,m ,m
When a client has a placenta previa, the placenta implants in the lower part of the
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
uterus and obstructs the cervical os (the opening to the vagina). The nurse should
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
,,m clarify this prescription because any manipulation can cause tearing of the placenta
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
,m and increased bleeding.
,m ,m
A nurse is caring for a client who is at 37 wks gestation and is undergoing a
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
nonstress test. The FHR is 130 without accelerations for the past 10 min. What
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
action should the nurse take? - ANS-use vibroacoustic stim on the client's abd for 3
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
seconds
,m
The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
activity because the fetus is most likely sleeping. Fetal movement should cause
,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m ,m
accelerations in the FHR.
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A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse
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notes that the client is rubella non-immune, positive for group A beta-hemolytic strep,
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and has a blood type O neg. What action should the nurse take? - ANS-instruct the
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client to obtain a rubella immunization after delivery
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A nurse is reviewing the med record of a client who is at 39 wks gestation and has
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polyhydramnios. What finding should the nurse expect? - ANS-fetal GI anomaly
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Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn
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fetus. Gastrointestinal malformations and neurologic disorders are expected findings
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for a fetus experiencing the effects of polyhydramnios.
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A nurse is caring for a client who is in the latent phase of labor and is experiencing
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low back pain. What action should the nurse take? - ANS-apply pressure to the
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client's sacral area during contractions
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A nurse is teaching a client who has pre-eclampsia and is to receive magnesium
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sulfate via continuous IV infusion about expected adverse effects. What adverse
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effects should the nurse include in the teaching? - ANS-feeling of warmth
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The nurse should tell the client to expect the feeling of warmth all over her body while
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the magnesium sulfate is infusing.
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A nurse is teaching a client who is at 12 wks gestation about manifestations of
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potential complications that she should report to her provider. What info should the
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nurse include in the teaching? - ANS-swelling of the face
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A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in
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the first trimester. What info should the nurse include in the teaching? - ANS-you will
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need to have a full bladder during the ultrasound
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MY ANSWER ,m
, The nurse should tell the client that a full bladder helps to lift the gravid uterus out of
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the pelvis during the examination. Therefore, it is important to ensure that the client
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has a full bladder to obtain the most accurate image of the fetus.
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A nurse is assessing a client who is 34 wks gestation and has mild placental
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abruption. What finding should the nurse expect? - ANS-dark red vaginal bleeding
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The nurse should expect the client who has a mild placental abruption to have
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minimal dark red vaginal bleeding.
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A nurse is caring for a client whose last menstrual period began july 8. Using Nageles
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rule, the nurse should identify the client's estimated DOB as what? - ANS-. april 15
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A nurse is caring for a client who is at 39 wks gestation and is in the active phase of
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labor. The nurse observes late decels in the FHR. What finding should the nurse
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identify as the cause of late decels? - ANS-uteroplacental insufficiency
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A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium
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sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the
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nurse report to the provider? - ANS-urinary output 20 mL/hr
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The nurse should report a urinary output of 20 mL/hr because this can indicate
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inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A
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decrease in urinary output can also indicate a decrease in renal perfusion secondary
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to a worsening of the client's pre-eclampsia.
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A nurse is teaching a client who is at 13 wks gestation about the treatment of
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incompetent cervix with cervical cerclage. What statement by the client indicates an
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understanding of teaching? - ANS-I should go to the hospital if I think I may be in
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labor
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Cervical cerclage prevents premature opening of the cervix during pregnancy. The
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client should immediately go to a facility for evaluation if she experiences any
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manifestations of labor while the cerclage is in place. If the client experiences
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preterm uterine contractions she might require tocolytic therapy.
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A nurse is admitting a client who is in labor and experiencing moderate bright red
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vaginal bleeding. What action should the nurse take? - ANS-obtain blood samples for
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baseline lab values
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The nurse should obtain samples of the client's blood for baseline testing of
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hemoglobin and hematocrit levels.
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A nurse is caring for a client who is at 38 wks of gestation and reports no fetal
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movement for 24 hr. What action should the nurse take? - ANS-auscultate for a FHR
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