Maternal New born ATI Proctored Exam
Questions and Complete Answers
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? - Answer: betamethasone
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? - Answer: urine test for presence of HCG
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 - Answer: palpable fetal movement
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse
expect? - Answer: renal agenesis
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? - Answer: uterine contractions
The nurse should expect the client to be experiencing uterine contractions due to abdominal
trauma.
A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings
should the nurse expect? - Answer: 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.
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? - Answer: 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.
A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse
include in the teaching? - Answer: you should continue to take zidovudine throughout the
pregnancy
-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.
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? - Answer:
blurred or double vision
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? - Answer:
decrease the dose of oxytocin by half
The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine
tachysystole.
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? - Answer: 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.
,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? - Answer: 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.
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? - Answer: use
vibroacoustic stim on the client's abd for 3 seconds
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.
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? - Answer: instruct the client to obtain a rubella immunization after
delivery
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? - Answer: 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.
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? - Answer: apply pressure to the client's sacral area during
contractions
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? - Answer: 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 teaching a client who is at 12 wks gestation about manifestations of potential
complications that she should report to her provider. What info should the nurse include in the
teaching? - Answer: swelling of the face
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? - Answer: 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.
A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding
should the nurse expect? - Answer: 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 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? - Answer: . april 15
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? -
Answer: uteroplacental insufficiency
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? - Answer: 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.
Questions and Complete Answers
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? - Answer: betamethasone
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? - Answer: urine test for presence of HCG
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 - Answer: palpable fetal movement
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse
expect? - Answer: renal agenesis
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? - Answer: uterine contractions
The nurse should expect the client to be experiencing uterine contractions due to abdominal
trauma.
A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings
should the nurse expect? - Answer: 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.
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? - Answer: 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.
A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse
include in the teaching? - Answer: you should continue to take zidovudine throughout the
pregnancy
-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.
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? - Answer:
blurred or double vision
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? - Answer:
decrease the dose of oxytocin by half
The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine
tachysystole.
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? - Answer: 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.
,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? - Answer: 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.
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? - Answer: use
vibroacoustic stim on the client's abd for 3 seconds
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.
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? - Answer: instruct the client to obtain a rubella immunization after
delivery
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? - Answer: 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.
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? - Answer: apply pressure to the client's sacral area during
contractions
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? - Answer: 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 teaching a client who is at 12 wks gestation about manifestations of potential
complications that she should report to her provider. What info should the nurse include in the
teaching? - Answer: swelling of the face
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? - Answer: 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.
A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding
should the nurse expect? - Answer: 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 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? - Answer: . april 15
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? -
Answer: uteroplacental insufficiency
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? - Answer: 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.
