RN Maternal Newborn Online Practice 2019 A – Actual Exam Questions & 100%
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A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the
following actions is the nurse’s priority?
a. check the client’s capillary refill
b. massage the fundus
c. insert an indwelling urinary catheter for the client
d. preapre the client for a blood transfusion
c. massage the client’s fundus
Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock.
This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's
priority is to massage the client's fundus to minimize blood loss.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings
contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
a. late decelerations
b. moderate variability of the FHR
c. cessation of uterine dilation
d. prolonged active phase of labor
a. late decelerations
Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the
administration of oxytocin and should be reported to the provider.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the
nurse expect?
a. 2+ deep tendon reflexes
b. proteinuria of 200 mg in 24 hr specimen
c. polyuria
d. blurred vision
d. blurred vision
The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and
decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision,
or dark spots in the visual field.
,A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following
manifestations should the nurse expect?
a. elevated temperature
b. boggy uterus
c. client report of vaginal pain
d. client report of yellow exudate vagina drainage
c. client report of vaginal pain
The nurse should expect a client who has a vaginal hematoma will report vaginal or rectal pain or discomfort
due to localized swelling.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse
should plan to prepare the client for which of the following diagnostic tests?
a. biophysical profile
b. amniocentesis
c. cordocentesis
d. klehaeur-betke test
a. biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile
will provide further evaluation with a real-time ultrasound.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which
of the following findings should the nurse include as an adverse effect of this medication?
a. depression
b. polyuria
c. hypotension
d. urticaria
a. depression
The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives.
Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea,
breakthrough bleeding, and breast tenderness.
A nurse is caring for postpartum client who is receiving heparin via a continuous IV infusion for
thrombophlebitis in her left calf. Which of the following actions should the nurse take?
a.Administer aspirin for pain.
b.Maintain the client on bed rest.
c.Massage the affected leg every 12 hr.
, d.Apply cold compresses to the affected calf.
b.Maintain the client on bed rest.
The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary
embolism. Elevation of the affected leg is recommended.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for
misoprostol? Which of the following
a. "I can administer oxytocin 4 hours after the insertion of the medication."
b. "You will need a full bladder prior to the insertion of the medication."
c."Remain in a side-lying position for 15 minutes after the medication is inserted."
d."An antacid will be given 20 minutes prior to the insertion of the medication." instruction should the nurse
include in the teaching?
a. "I can administer oxytocin 4 hours after the insertion of the medication."
The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be
administered following misoprostol for clients who have cervical ripening and have not begun labor.
A nurse is assessing 4 newborns. Which of the following findings should the nurse report to the provider?
a.A newborn who is 26 hr old and has erythema toxicum on his face
b.A newborn who is 32 hr old and has not passed a meconium stool
c.A newborn who is 12 hr old and has pink-tinged urine
d.A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
d.A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and
can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to
treat preterm labor. The nurse should notify the provider of which of the following adverse effects?
a. client reports nausea
b. urinary output of 40 ml/hr
c.respiratory rate 10/min
d. client reports feeling flushed
c. respiratory rate 10/min
The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of
magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the
following statement by the client indicates an understanding of the teaching?
Verified Answers – Detailed Rationales Included – Trusted Study Pack for ATI
Success – Graded A+
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the
following actions is the nurse’s priority?
a. check the client’s capillary refill
b. massage the fundus
c. insert an indwelling urinary catheter for the client
d. preapre the client for a blood transfusion
c. massage the client’s fundus
Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock.
This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's
priority is to massage the client's fundus to minimize blood loss.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings
contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
a. late decelerations
b. moderate variability of the FHR
c. cessation of uterine dilation
d. prolonged active phase of labor
a. late decelerations
Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the
administration of oxytocin and should be reported to the provider.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the
nurse expect?
a. 2+ deep tendon reflexes
b. proteinuria of 200 mg in 24 hr specimen
c. polyuria
d. blurred vision
d. blurred vision
The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and
decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision,
or dark spots in the visual field.
,A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following
manifestations should the nurse expect?
a. elevated temperature
b. boggy uterus
c. client report of vaginal pain
d. client report of yellow exudate vagina drainage
c. client report of vaginal pain
The nurse should expect a client who has a vaginal hematoma will report vaginal or rectal pain or discomfort
due to localized swelling.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse
should plan to prepare the client for which of the following diagnostic tests?
a. biophysical profile
b. amniocentesis
c. cordocentesis
d. klehaeur-betke test
a. biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile
will provide further evaluation with a real-time ultrasound.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which
of the following findings should the nurse include as an adverse effect of this medication?
a. depression
b. polyuria
c. hypotension
d. urticaria
a. depression
The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives.
Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea,
breakthrough bleeding, and breast tenderness.
A nurse is caring for postpartum client who is receiving heparin via a continuous IV infusion for
thrombophlebitis in her left calf. Which of the following actions should the nurse take?
a.Administer aspirin for pain.
b.Maintain the client on bed rest.
c.Massage the affected leg every 12 hr.
, d.Apply cold compresses to the affected calf.
b.Maintain the client on bed rest.
The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary
embolism. Elevation of the affected leg is recommended.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for
misoprostol? Which of the following
a. "I can administer oxytocin 4 hours after the insertion of the medication."
b. "You will need a full bladder prior to the insertion of the medication."
c."Remain in a side-lying position for 15 minutes after the medication is inserted."
d."An antacid will be given 20 minutes prior to the insertion of the medication." instruction should the nurse
include in the teaching?
a. "I can administer oxytocin 4 hours after the insertion of the medication."
The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be
administered following misoprostol for clients who have cervical ripening and have not begun labor.
A nurse is assessing 4 newborns. Which of the following findings should the nurse report to the provider?
a.A newborn who is 26 hr old and has erythema toxicum on his face
b.A newborn who is 32 hr old and has not passed a meconium stool
c.A newborn who is 12 hr old and has pink-tinged urine
d.A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
d.A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and
can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to
treat preterm labor. The nurse should notify the provider of which of the following adverse effects?
a. client reports nausea
b. urinary output of 40 ml/hr
c.respiratory rate 10/min
d. client reports feeling flushed
c. respiratory rate 10/min
The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of
magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the
following statement by the client indicates an understanding of the teaching?
