NUR 242 ATI Q 1
A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and
has polyhydramnios. Which of the following findings should the nurse expect. -
✔️✔️Fetal gastrointestinal 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.
A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The
nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic
streptococci, and has a blood type of O negative. Which of the following actions should
the nurse take? - ✔️✔️Instruct the client to obtain rubella immunization after delivery;
This client is not immune to rubella and should receive this immunization after delivery.
A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental
abruption. Which of the following findings should the nurse expect? - ✔️✔️Dark red
vaginal bleeding;
The nurse should expect the client who has a mild placental abruption to have minimal
dark red vaginal bleeding.
A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid
about potential effects of the fibroid during pregnancy. Which of the following
information should the nurse include in the teaching? - ✔️✔️The fibroid can increase
the risk for postpartum hemorrhage;
Uterine fibroids can increase the risk of postpartum hemorrhage due to the increase in
blood supply to the uterus, which supports the fibroid
A nurse is caring for a client who is in the latent phase of labor and is experiencing low
back pain. Which of the following actions should the nurse take? - ✔️✔️Apply pressure
to the client's sacral area during contractions;
The nurse should provide counter pressure to the sacral area with a plan or a firm
object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head
away from the sacral nerves, which decreases pain.
A nurse is caring for a client who has oligohydramnios. Which of the following fetal
anomalies should the nurse expect? - ✔️✔️Renal agenesis;
, Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third
trimester of pregnancy and occurs when there is a renal system dysfunction of
obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios.
A nurse is teaching a client who is at 12 weeks of gestation and has human
immunodeficiency virus (HIV). Which of the following statements should the nurse
include in the teaching? - ✔️✔️You should continue to take zidovudine throughout the
pregnancy;
The nurse should inform the client that taking prescription antiviral medication every day
decreases the risk of transmission of HIV to her newborn.
A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal
movement for 24 hr. Which of the following actions should the nurse take? -
✔️✔️Auscultate for a fetal heart rate;
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.
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate
via continuous IV infusion about expected adverse effects. Which of the following
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.
A nurse is assessing a client who is at 35 weeks of gestation and is receiving
magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the
following findings 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.
A nurse is caring for a client whose last menstrual period (LMP) began July 8. Using
Nagele's rule, the nurse should identify the client's estimated date of birth (EDB) as
which of the following? - ✔️✔️April 15;
Using Nagele's rule, the nurse determines the EDB by counting back 3 months from the
first day of the LMP and adding 7 days.
A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and
has polyhydramnios. Which of the following findings should the nurse expect. -
✔️✔️Fetal gastrointestinal 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.
A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The
nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic
streptococci, and has a blood type of O negative. Which of the following actions should
the nurse take? - ✔️✔️Instruct the client to obtain rubella immunization after delivery;
This client is not immune to rubella and should receive this immunization after delivery.
A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental
abruption. Which of the following findings should the nurse expect? - ✔️✔️Dark red
vaginal bleeding;
The nurse should expect the client who has a mild placental abruption to have minimal
dark red vaginal bleeding.
A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid
about potential effects of the fibroid during pregnancy. Which of the following
information should the nurse include in the teaching? - ✔️✔️The fibroid can increase
the risk for postpartum hemorrhage;
Uterine fibroids can increase the risk of postpartum hemorrhage due to the increase in
blood supply to the uterus, which supports the fibroid
A nurse is caring for a client who is in the latent phase of labor and is experiencing low
back pain. Which of the following actions should the nurse take? - ✔️✔️Apply pressure
to the client's sacral area during contractions;
The nurse should provide counter pressure to the sacral area with a plan or a firm
object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head
away from the sacral nerves, which decreases pain.
A nurse is caring for a client who has oligohydramnios. Which of the following fetal
anomalies should the nurse expect? - ✔️✔️Renal agenesis;
, Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third
trimester of pregnancy and occurs when there is a renal system dysfunction of
obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios.
A nurse is teaching a client who is at 12 weeks of gestation and has human
immunodeficiency virus (HIV). Which of the following statements should the nurse
include in the teaching? - ✔️✔️You should continue to take zidovudine throughout the
pregnancy;
The nurse should inform the client that taking prescription antiviral medication every day
decreases the risk of transmission of HIV to her newborn.
A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal
movement for 24 hr. Which of the following actions should the nurse take? -
✔️✔️Auscultate for a fetal heart rate;
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.
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate
via continuous IV infusion about expected adverse effects. Which of the following
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.
A nurse is assessing a client who is at 35 weeks of gestation and is receiving
magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the
following findings 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.
A nurse is caring for a client whose last menstrual period (LMP) began July 8. Using
Nagele's rule, the nurse should identify the client's estimated date of birth (EDB) as
which of the following? - ✔️✔️April 15;
Using Nagele's rule, the nurse determines the EDB by counting back 3 months from the
first day of the LMP and adding 7 days.
