Maternal newborn ati proctored exam FULL ANSWERS
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1. A nurse is caring for a client who is at 32 wks gestation and is experiencing
preterm labor. What meds should the nurse plan to administer?: betametha-
sone
2. A nurse at a prenatal clinic is caring for a client who suspects she may be
pregnant and asks the nurse how the provider will confirm her pregnancy. The
nurse should inform the client that what lab test will be used to confirm her
pregnancy?: urine test for presence of HCG
3. A nurse is caring for a client who believes she may be pregnant. What finding
should the nurse identify as a positive sign of pregnancy?
a. palpable fetal movement: palpable fetal movement
4. A nurse is caring for a client who has oligohydraminios. What fetal anom-
alies should the nurse expect?: renal agenesis
5. A nurse is assessing a client who is at 37 wks gestation and has a suspected
pelvic fracture due to blunt abd trauma. What findings should the nurse
expect?: uterine contractions
The nurse should expect the client to be experiencing uterine contractions due to
abdominal trauma.
6. A nurse is assessing a client who is at 12 wks gestation and has hyda-
tidiform mole. What findings should the nurse expect?: dark brown vaginal
discharge
A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of
the chorionic villi, which gives rise to multiple cysts. The products of conception
transform into a large number of edematous, fluid-filled vesicles. As cells slough off
the uterine wall, vaginal discharge is usually dark brown and can contain grapelike
clusters.
7. A nurse is assessing a client who is at 35 weeks of gestation and has mild
gestational HTN. What finding should the nurse identify as the priority?: 480
mL urine output in 24 hrs
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is 480 mL of urine output in 24 hr because the
minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate
progression of preeclampsia to preeclampsia with severe features, which requires
immediate intervention. Therefore, this is the priority finding.
8. A nurse is teaching a client who is at 12 wks gestation and has HIV. What
statement should the nurse include in the teaching?: you should continue to
take zidovudine throughout the pregnancy
, Maternal newborn ati proctored exam FULL ANSWERS
Study online at https://quizlet.com/_ew62sc
-can be transmitted through breastfeeding
-she can continue to have sex
The nurse should inform the client that taking prescription antiviral medication every
day decreases the risk of transmission of HIV to her newborn.
9. A nurse is providing teaching to a client who is at 8 wks gestation about
manifestations to report to the provider during pregnancy. What info should
the nurse include in the teaching?: blurred or double vision
10. A nurse is caring for a client who is in the latent phase of labor and is
receiving oxytocin via continuous IV infusion. The nurse notes that the client
is having contractions every 2 min which last 100-110 seconds that the fetal
heart rate is reassuring. What action should the nurse take?: decrease the dose
of oxytocin by half
The nurse should decrease the dose of oxytocin by half because the client is
experiencing uterine tachysystole.
11. A nurse is caring for a client who is in active labor and has meconium
staining of the amniotic fluid. The nurse notes a reassuring FHR tracing
from the external fetal monitor. What action should the nurse take?: prepare
equipment needed for newborn resuscitation
The nurse should ensure that all supplies and equipment needed for resuscitation
of the newborn are readily available for every delivery. Endotracheal suctioning
is recommended in cases of meconium staining only if the newborn has poor
respiratory effort, decreased muscle tone, and bradycardia after delivery.
12. A nurse is reviewing the medical record of a client who is at 33 wks
gestation and has placenta previa and bleeding. What scripts should the nurse
clarify with the provider?: perform a vaginal exam
When a client has a placenta previa, the placenta implants in the lower part of the
uterus and obstructs the cervical os (the opening to the vagina). The nurse should
clarify this prescription because any manipulation can cause tearing of the placenta
and increased bleeding.
13. A nurse is caring for a client who is at 37 wks gestation and is undergoing
a nonstress test. The FHR is 130 without accelerations for the past 10 min.
What action should the nurse take?: use vibroacoustic stim on the client's abd
for 3 seconds
, Maternal newborn ati proctored exam FULL ANSWERS
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The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit
fetal activity because the fetus is most likely sleeping. Fetal movement should cause
accelerations in the FHR.
14. A nurse is reviewing lab results for a client who is at 37 wks gestation.
The nurse notes that the client is rubella non-immune, positive for group A
beta-hemolytic strep, and has a blood type O neg. What action should the
nurse take?: instruct the client to obtain a rubella immunization after delivery
15. A nurse is reviewing the med record of a client who is at 39 wks gestation
and has polyhydramnios. What finding should the nurse expect?: fetal GI
anomaly
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn
fetus. Gastrointestinal malformations and neurologic disorders are expected findings
for a fetus experiencing the effects of polyhydramnios.
16. A nurse is caring for a client who is in the latent phase of labor and
is experiencing low back pain. What action should the nurse take?: apply
pressure to the client's sacral area during contractions
17. A nurse is teaching a client who has pre-eclampsia and is to receive
magnesium sulfate via continuous IV infusion about expected adverse effects.
What adverse effects should the nurse include in the teaching?: feeling of
warmth
The nurse should tell the client to expect the feeling of warmth all over her body while
the magnesium sulfate is infusing.
18. A nurse is teaching a client who is at 12 wks gestation about manifesta-
tions of potential complications that she should report to her provider. What
info should the nurse include in the teaching?: swelling of the face
19. A nurse is teaching a client who is at 10 wks gestation about an abd.
ultrasound in the first trimester. What info should the nurse include in the
teaching?: you will need to have a full bladder during the ultrasound
MY ANSWER
The nurse should tell the client that a full bladder helps to lift the gravid uterus out of
the pelvis during the examination. Therefore, it is important to ensure that the client
has a full bladder to obtain the most accurate image of the fetus.
20. A nurse is assessing a client who is 34 wks gestation and has mild
placental abruption. What finding should the nurse expect?: dark red vaginal
bleeding
, Maternal newborn ati proctored exam FULL ANSWERS
Study online at https://quizlet.com/_ew62sc
The nurse should expect the client who has a mild placental abruption to have
minimal dark red vaginal bleeding.
21. A nurse is caring for a client whose last menstrual period began july 8.
Using Nageles rule, the nurse should identify the client's estimated DOB as
what?: . april 15
22. A nurse is caring for a client who is at 39 wks gestation and is in the active
phase of labor. The nurse observes late decels in the FHR. What finding should
the nurse identify as the cause of late decels?: uteroplacental insufficiency
23. A nurse is assessing a client who is at 35 wks gestation and is receiving
magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What
finding should the nurse report to the provider?: urinary output 20 mL/hr
The nurse should report a urinary output of 20 mL/hr because this can indicate
inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A
decrease in urinary output can also indicate a decrease in renal perfusion secondary
to a worsening of the client's pre-eclampsia.
24. A nurse is teaching a client who is at 13 wks gestation about the treatment
of incompetent cervix with cervical cerclage. What statement by the client
indicates an understanding of teaching?: I should go to the hospital if I think I
may be in labor
Cervical cerclage prevents premature opening of the cervix during pregnancy. The
client should immediately go to a facility for evaluation if she experiences any
manifestations of labor while the cerclage is in place. If the client experiences
preterm uterine contractions she might require tocolytic therapy.
25. A nurse is admitting a client who is in labor and experiencing moderate
bright red vaginal bleeding. What action should the nurse take?: obtain blood
samples for baseline lab values
The nurse should obtain samples of the client's blood for baseline testing of hemo-
globin and hematocrit levels.
26. A nurse is caring for a client who is at 38 wks of gestation and reports no
fetal movement for 24 hr. What action should the nurse take?: auscultate for a
FHR
Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The
nurse should auscultate for the fetal heart rate using a Doppler device or an external
fetal monitor. This is the priority nursing action.
Study online at https://quizlet.com/_ew62sc
1. A nurse is caring for a client who is at 32 wks gestation and is experiencing
preterm labor. What meds should the nurse plan to administer?: betametha-
sone
2. A nurse at a prenatal clinic is caring for a client who suspects she may be
pregnant and asks the nurse how the provider will confirm her pregnancy. The
nurse should inform the client that what lab test will be used to confirm her
pregnancy?: urine test for presence of HCG
3. A nurse is caring for a client who believes she may be pregnant. What finding
should the nurse identify as a positive sign of pregnancy?
a. palpable fetal movement: palpable fetal movement
4. A nurse is caring for a client who has oligohydraminios. What fetal anom-
alies should the nurse expect?: renal agenesis
5. A nurse is assessing a client who is at 37 wks gestation and has a suspected
pelvic fracture due to blunt abd trauma. What findings should the nurse
expect?: uterine contractions
The nurse should expect the client to be experiencing uterine contractions due to
abdominal trauma.
6. A nurse is assessing a client who is at 12 wks gestation and has hyda-
tidiform mole. What findings should the nurse expect?: dark brown vaginal
discharge
A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of
the chorionic villi, which gives rise to multiple cysts. The products of conception
transform into a large number of edematous, fluid-filled vesicles. As cells slough off
the uterine wall, vaginal discharge is usually dark brown and can contain grapelike
clusters.
7. A nurse is assessing a client who is at 35 weeks of gestation and has mild
gestational HTN. What finding should the nurse identify as the priority?: 480
mL urine output in 24 hrs
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is 480 mL of urine output in 24 hr because the
minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate
progression of preeclampsia to preeclampsia with severe features, which requires
immediate intervention. Therefore, this is the priority finding.
8. A nurse is teaching a client who is at 12 wks gestation and has HIV. What
statement should the nurse include in the teaching?: you should continue to
take zidovudine throughout the pregnancy
, Maternal newborn ati proctored exam FULL ANSWERS
Study online at https://quizlet.com/_ew62sc
-can be transmitted through breastfeeding
-she can continue to have sex
The nurse should inform the client that taking prescription antiviral medication every
day decreases the risk of transmission of HIV to her newborn.
9. A nurse is providing teaching to a client who is at 8 wks gestation about
manifestations to report to the provider during pregnancy. What info should
the nurse include in the teaching?: blurred or double vision
10. A nurse is caring for a client who is in the latent phase of labor and is
receiving oxytocin via continuous IV infusion. The nurse notes that the client
is having contractions every 2 min which last 100-110 seconds that the fetal
heart rate is reassuring. What action should the nurse take?: decrease the dose
of oxytocin by half
The nurse should decrease the dose of oxytocin by half because the client is
experiencing uterine tachysystole.
11. A nurse is caring for a client who is in active labor and has meconium
staining of the amniotic fluid. The nurse notes a reassuring FHR tracing
from the external fetal monitor. What action should the nurse take?: prepare
equipment needed for newborn resuscitation
The nurse should ensure that all supplies and equipment needed for resuscitation
of the newborn are readily available for every delivery. Endotracheal suctioning
is recommended in cases of meconium staining only if the newborn has poor
respiratory effort, decreased muscle tone, and bradycardia after delivery.
12. A nurse is reviewing the medical record of a client who is at 33 wks
gestation and has placenta previa and bleeding. What scripts should the nurse
clarify with the provider?: perform a vaginal exam
When a client has a placenta previa, the placenta implants in the lower part of the
uterus and obstructs the cervical os (the opening to the vagina). The nurse should
clarify this prescription because any manipulation can cause tearing of the placenta
and increased bleeding.
13. A nurse is caring for a client who is at 37 wks gestation and is undergoing
a nonstress test. The FHR is 130 without accelerations for the past 10 min.
What action should the nurse take?: use vibroacoustic stim on the client's abd
for 3 seconds
, Maternal newborn ati proctored exam FULL ANSWERS
Study online at https://quizlet.com/_ew62sc
The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit
fetal activity because the fetus is most likely sleeping. Fetal movement should cause
accelerations in the FHR.
14. A nurse is reviewing lab results for a client who is at 37 wks gestation.
The nurse notes that the client is rubella non-immune, positive for group A
beta-hemolytic strep, and has a blood type O neg. What action should the
nurse take?: instruct the client to obtain a rubella immunization after delivery
15. A nurse is reviewing the med record of a client who is at 39 wks gestation
and has polyhydramnios. What finding should the nurse expect?: fetal GI
anomaly
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn
fetus. Gastrointestinal malformations and neurologic disorders are expected findings
for a fetus experiencing the effects of polyhydramnios.
16. A nurse is caring for a client who is in the latent phase of labor and
is experiencing low back pain. What action should the nurse take?: apply
pressure to the client's sacral area during contractions
17. A nurse is teaching a client who has pre-eclampsia and is to receive
magnesium sulfate via continuous IV infusion about expected adverse effects.
What adverse effects should the nurse include in the teaching?: feeling of
warmth
The nurse should tell the client to expect the feeling of warmth all over her body while
the magnesium sulfate is infusing.
18. A nurse is teaching a client who is at 12 wks gestation about manifesta-
tions of potential complications that she should report to her provider. What
info should the nurse include in the teaching?: swelling of the face
19. A nurse is teaching a client who is at 10 wks gestation about an abd.
ultrasound in the first trimester. What info should the nurse include in the
teaching?: you will need to have a full bladder during the ultrasound
MY ANSWER
The nurse should tell the client that a full bladder helps to lift the gravid uterus out of
the pelvis during the examination. Therefore, it is important to ensure that the client
has a full bladder to obtain the most accurate image of the fetus.
20. A nurse is assessing a client who is 34 wks gestation and has mild
placental abruption. What finding should the nurse expect?: dark red vaginal
bleeding
, Maternal newborn ati proctored exam FULL ANSWERS
Study online at https://quizlet.com/_ew62sc
The nurse should expect the client who has a mild placental abruption to have
minimal dark red vaginal bleeding.
21. A nurse is caring for a client whose last menstrual period began july 8.
Using Nageles rule, the nurse should identify the client's estimated DOB as
what?: . april 15
22. A nurse is caring for a client who is at 39 wks gestation and is in the active
phase of labor. The nurse observes late decels in the FHR. What finding should
the nurse identify as the cause of late decels?: uteroplacental insufficiency
23. A nurse is assessing a client who is at 35 wks gestation and is receiving
magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What
finding should the nurse report to the provider?: urinary output 20 mL/hr
The nurse should report a urinary output of 20 mL/hr because this can indicate
inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A
decrease in urinary output can also indicate a decrease in renal perfusion secondary
to a worsening of the client's pre-eclampsia.
24. A nurse is teaching a client who is at 13 wks gestation about the treatment
of incompetent cervix with cervical cerclage. What statement by the client
indicates an understanding of teaching?: I should go to the hospital if I think I
may be in labor
Cervical cerclage prevents premature opening of the cervix during pregnancy. The
client should immediately go to a facility for evaluation if she experiences any
manifestations of labor while the cerclage is in place. If the client experiences
preterm uterine contractions she might require tocolytic therapy.
25. A nurse is admitting a client who is in labor and experiencing moderate
bright red vaginal bleeding. What action should the nurse take?: obtain blood
samples for baseline lab values
The nurse should obtain samples of the client's blood for baseline testing of hemo-
globin and hematocrit levels.
26. A nurse is caring for a client who is at 38 wks of gestation and reports no
fetal movement for 24 hr. What action should the nurse take?: auscultate for a
FHR
Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The
nurse should auscultate for the fetal heart rate using a Doppler device or an external
fetal monitor. This is the priority nursing action.
