ATI. MATERNAL-NEWBORN QUESTIONS WITH CORRECT ANSWERS
1. Two h6days h6after h6delivery, h6a h6postpartum h6client h6prepares h6for h6discharge. h6What
h6should h6the h6nurs h6eteach h6her h6about h6lochia h6flow?
Incorrect: h6 Lochia h6 does h6 change h6color h6 but h6 goes h6from h6 lochia h6 rubra h6 (bright h6 red) h6 on h6 days
h6 1-
3, h6to h6lochiaserosa h6(pinkish h6brown) h6on h6days h64-9, h6to h6lochia h6alba h6(creamy h6white) h6days
h6 10-21. h6Incorrect: h6Numerous h6clots h6are h6abnormal h6and h6should h6be h6reported h6to h6the
h6 physician.
Incorrect: h6Saturation h6of h6the h6perineal h6pad h6is h6considered h6abnormal h6and h6may h6indicate
h6postpartu h6mhemorrhage.
Correct: h6Lochia h6normally h6lasts h6for h6about h621 h6days, h6and h6changes h6from h6a h6bright h6red,
h6to h6pinkish h6brown, h6to h6creamy h6white.
The h6color h6of h6the h6lochia h6changes h6from h6a h6bright h6red h6to h6white h6after
h6 four7da h6ysNumerous h6large h6clots h6are h6normal h6for h6the h6next h6three h6to h6four
h6 days
Saturation h6of h6the h6perineal h6pad h6with h6blood h6is h6expected h6when h6getting h6up
h6 from h6the h6be h6dLochia h6should h6last h6for h6about h63 h6weeks, h6changing h6color
h6 every h6few7days
2. A h6nurse h6monitors h6fetal h6well-
being h6by h6means h6of h6an h6external h6monitor. h6At h6the h6peak h6of h6the h6contractions, h6the h6fetal
h6heart h6rate h6h h6as h6repeatedly h6dropped h630 h6beats/min h6below h6the h6baseline.
h6Latedecelerations h6are h6suspected h6and h6the h6nurse h6notifies h6the h6physician. h6Which h6is h6the
h6rationale h6for7thisaction?
Incorrect: h6A h6nuchal h6cord h6(cord h6around h6the h6neck) h6is h6associated h6with h6variable h6decelerations,
h6not h6la h6tedecelerations.
Incorrect: h6Variable h6decelerations h6(not h6late h6decelerations) h6are h6associated h6with h6cord
h6 compression.
Incorrect: h6Late h6decelerations h6are h6a h6result h6of h6hypoxia. h6They7are h6not h6reflective h6of h6the
h6strength h6ofmat h6ernal h6contractions.
Correct: h6Late h6decelerations h6are h6associated h6with h6uteroplacental h6insufficiency h6and
,h6are h6a h6sign h6of h6fetal h6hypoxia. h6Repeated h6late h6decelerations h6indicate h6fetal h6distress.
The h6umbilical h6cord h6is h6 wrapped h6 tightly h6around h6the h6 fetus' h6 neck
The h6fetal h6 cord h6is h6being h6 compressed h6 due h6 to h6 rapid h6 descent h6 of h6 the h6 fetal h6 head
,Maternal h6contractions h6are h6not h6adequate h6enough h6to h6deliver
h6 the h6fetu h6sThe h6fetus h6is h6not h6receiving h6adequate h6oxygen
h6 and h6is h6in h6distress
3. Which h6preoperative h6nursing h6interventions h6should h6be h6included h6for h6a h6client h6who h6is
h6scheduled h6tohave h6an h6emergency h6cesarean h6birth?
Incorrect: h6Monitoring h6O2 h6saturations h6 and h6 administering h6pain h6 medications h6 are
h6postoperativeinterve h6ntions.
Incorrect: h6Taking h6vital h6signs h6every h615 h6minutes h6is h6a h6postoperative h6intervention.
h6Instructing h6the h6cl h6ient h6regarding h6breathing h6exercises h6is h6not h6appropriate h6in h6a h6crisis
h6situation h6when h6the h6client's h6anxiet h 6 y h6is h6high, h6because h6information h6would h6probably
h6not h6be h6retained. h6In h6an h6emergency, h6there h6istime h6on h6ly7for h6essential h6interventions.
Correct: h6Because h6this h6is h6an h6emergency, h6surgery h6must h6be h6performed h6quickly.
h6Anxiety7of h6the h6client h6and h6the h6family h6will h6be h6high. h6Inserting h6an h6indwelling
h6catheter h6helps h6to h6keep h6the h6blad h6der h6empty h6and h6free h6from h6injury h6when h6the
h6incision h6is h6made.
Incorrect: h6The h6nurse h6should h6have h6assessed h6breath h6sounds h6upon h6admission. h6Breath
h6sounds h6are h6im h6portant h6if h6the h6client h6is h6to h6receive h6general h6anesthesia, h6but h6the
h6anesthesiologist h6will h6be h6listening h6to h6breath h6sounds h6in h6surgery7in h6that h6case.
Monitor h6oxygen h6saturation h6and h6administer h6 pain h6medication.
Assess h6vital h6signs h6every h615 h6minutes h6and h6instruct h6the h6client h6about h6postoperative
h6 care.Alle h6viate h6anxiety h6and h6insert h6an h6indwelling h6catheter.
Perform h6a h6sterile h6vaginal h6 examination h6and h6 assess h6breath h6 sounds.
4. Which h6nursing7instruction h6should h6be h6given h6to h6the h6breastfeeding h6mother7regarding
h6care h6of h6t h6hebreasts h6after h6discharge?
Incorrect: h6Engorgement h6occurs h6on h6about7the h6third h6or h6fourth h6postpartum h6day h6and
h6is h6a h6resu h6ltof h6the h6breast h6milk h6formation. h6The h6primary h6way h6to h6relieve
h6engorgement h6is h6by h6pumping h6or h6longer h6nursing. h6Giving h6a h6bottle h6of h6formula h6will
h6compound h6the h6problem h6because h6the h6baby h6will h6not h6be h6hungry h6and h6will h6not
h6empty h6the h6breasts h6well.
Incorrect: h6Applying h6lotion h6to h6the h6nipples h6is h6not h6effective h6for h6keeping h6them h6soft.
h6Excessiveamou h6nts h6of h6lotion h6may7harbor h6microorganisms.
, Correct: h6In h6order h6to h6stimulate h6adequate h6milk h6production, h6the h6breasts h6should h6be
h6pumped h6ift h6he h6infant7is h6not h6sucking h6or7eating h6well, h6or h6if h6the h6breasts h6are h6not
h6fully h6emptied.
Incorrect: h6Using h6soap h6on h6the h6breasts h6dries h6the h6nipples h6and h6can h6cause
h6 crackin h6g.The h6baby h6should h6be h6given h6a h6bottle h6of h6formula h6if
h6 engorgement h6occurs.
The h6nipples h6should h6be h6covered h6with h6lotion h6when h6the h6baby h6is
h6 not h6nursin h6g.The h6breasts h6should h6be h6pumped h6if h6the h6baby h6is
h6 not h6sucking h6adequately. h6The h6breasts h6should h6be h6washed h6with
h6 soap h6and h6water h6once h6per7day.
5. A h6client h6in h6preterm h6labor7is h6admitted h6to h6the h6hospital. h6Which h6classification h6of
h6drugs h6should h6t h6henurse h6anticipate h6administering?
Correct: h6Tocolytics h6are h6used h6to h6stop h6labor. h6One h6of h6the h6most h6commonly h6used
h6tocolytic h6drug h6sis h6ritodrine h6(Yutopar).
Incorrect: h6Anticonvulsants h6are h6used h6for7clients h6with
h6pregnancy- h6induced h6hypertension h6who h6arelikely h6to h6seize.
Incorrect: h6The h6glucocorticoids h6(e.g., h6betamethasone h6and h6dexamethasone) h6are h6used h6for
h6accelerat h6ing h6fetal h6lung h6maturation h6and h6production h6of h6surfactant. h6They h6are h6commonly
h6used h6if h6themembran h6es h6are h6ruptured h6or h6labor h6cannot h6be h6stopped.
Incorrect: h6Anti-
infective h6are h6used h6if h6there h6is h6infection. h6Preterm h6labor h6may h6or7may7not h6involveruptured
h6membranes h6with h6its h6accompanying h6risk h6of h6infection.
Tocolytics
h6 Anti
h6 convulsantsGl
u
h6cocorticoidsA
nt h6i-infective
6. Which h6of h6the h6following h6 are h6probable h6 signs, h6 strongly h6indicating h6pregnancy?
1. Two h6days h6after h6delivery, h6a h6postpartum h6client h6prepares h6for h6discharge. h6What
h6should h6the h6nurs h6eteach h6her h6about h6lochia h6flow?
Incorrect: h6 Lochia h6 does h6 change h6color h6 but h6 goes h6from h6 lochia h6 rubra h6 (bright h6 red) h6 on h6 days
h6 1-
3, h6to h6lochiaserosa h6(pinkish h6brown) h6on h6days h64-9, h6to h6lochia h6alba h6(creamy h6white) h6days
h6 10-21. h6Incorrect: h6Numerous h6clots h6are h6abnormal h6and h6should h6be h6reported h6to h6the
h6 physician.
Incorrect: h6Saturation h6of h6the h6perineal h6pad h6is h6considered h6abnormal h6and h6may h6indicate
h6postpartu h6mhemorrhage.
Correct: h6Lochia h6normally h6lasts h6for h6about h621 h6days, h6and h6changes h6from h6a h6bright h6red,
h6to h6pinkish h6brown, h6to h6creamy h6white.
The h6color h6of h6the h6lochia h6changes h6from h6a h6bright h6red h6to h6white h6after
h6 four7da h6ysNumerous h6large h6clots h6are h6normal h6for h6the h6next h6three h6to h6four
h6 days
Saturation h6of h6the h6perineal h6pad h6with h6blood h6is h6expected h6when h6getting h6up
h6 from h6the h6be h6dLochia h6should h6last h6for h6about h63 h6weeks, h6changing h6color
h6 every h6few7days
2. A h6nurse h6monitors h6fetal h6well-
being h6by h6means h6of h6an h6external h6monitor. h6At h6the h6peak h6of h6the h6contractions, h6the h6fetal
h6heart h6rate h6h h6as h6repeatedly h6dropped h630 h6beats/min h6below h6the h6baseline.
h6Latedecelerations h6are h6suspected h6and h6the h6nurse h6notifies h6the h6physician. h6Which h6is h6the
h6rationale h6for7thisaction?
Incorrect: h6A h6nuchal h6cord h6(cord h6around h6the h6neck) h6is h6associated h6with h6variable h6decelerations,
h6not h6la h6tedecelerations.
Incorrect: h6Variable h6decelerations h6(not h6late h6decelerations) h6are h6associated h6with h6cord
h6 compression.
Incorrect: h6Late h6decelerations h6are h6a h6result h6of h6hypoxia. h6They7are h6not h6reflective h6of h6the
h6strength h6ofmat h6ernal h6contractions.
Correct: h6Late h6decelerations h6are h6associated h6with h6uteroplacental h6insufficiency h6and
,h6are h6a h6sign h6of h6fetal h6hypoxia. h6Repeated h6late h6decelerations h6indicate h6fetal h6distress.
The h6umbilical h6cord h6is h6 wrapped h6 tightly h6around h6the h6 fetus' h6 neck
The h6fetal h6 cord h6is h6being h6 compressed h6 due h6 to h6 rapid h6 descent h6 of h6 the h6 fetal h6 head
,Maternal h6contractions h6are h6not h6adequate h6enough h6to h6deliver
h6 the h6fetu h6sThe h6fetus h6is h6not h6receiving h6adequate h6oxygen
h6 and h6is h6in h6distress
3. Which h6preoperative h6nursing h6interventions h6should h6be h6included h6for h6a h6client h6who h6is
h6scheduled h6tohave h6an h6emergency h6cesarean h6birth?
Incorrect: h6Monitoring h6O2 h6saturations h6 and h6 administering h6pain h6 medications h6 are
h6postoperativeinterve h6ntions.
Incorrect: h6Taking h6vital h6signs h6every h615 h6minutes h6is h6a h6postoperative h6intervention.
h6Instructing h6the h6cl h6ient h6regarding h6breathing h6exercises h6is h6not h6appropriate h6in h6a h6crisis
h6situation h6when h6the h6client's h6anxiet h 6 y h6is h6high, h6because h6information h6would h6probably
h6not h6be h6retained. h6In h6an h6emergency, h6there h6istime h6on h6ly7for h6essential h6interventions.
Correct: h6Because h6this h6is h6an h6emergency, h6surgery h6must h6be h6performed h6quickly.
h6Anxiety7of h6the h6client h6and h6the h6family h6will h6be h6high. h6Inserting h6an h6indwelling
h6catheter h6helps h6to h6keep h6the h6blad h6der h6empty h6and h6free h6from h6injury h6when h6the
h6incision h6is h6made.
Incorrect: h6The h6nurse h6should h6have h6assessed h6breath h6sounds h6upon h6admission. h6Breath
h6sounds h6are h6im h6portant h6if h6the h6client h6is h6to h6receive h6general h6anesthesia, h6but h6the
h6anesthesiologist h6will h6be h6listening h6to h6breath h6sounds h6in h6surgery7in h6that h6case.
Monitor h6oxygen h6saturation h6and h6administer h6 pain h6medication.
Assess h6vital h6signs h6every h615 h6minutes h6and h6instruct h6the h6client h6about h6postoperative
h6 care.Alle h6viate h6anxiety h6and h6insert h6an h6indwelling h6catheter.
Perform h6a h6sterile h6vaginal h6 examination h6and h6 assess h6breath h6 sounds.
4. Which h6nursing7instruction h6should h6be h6given h6to h6the h6breastfeeding h6mother7regarding
h6care h6of h6t h6hebreasts h6after h6discharge?
Incorrect: h6Engorgement h6occurs h6on h6about7the h6third h6or h6fourth h6postpartum h6day h6and
h6is h6a h6resu h6ltof h6the h6breast h6milk h6formation. h6The h6primary h6way h6to h6relieve
h6engorgement h6is h6by h6pumping h6or h6longer h6nursing. h6Giving h6a h6bottle h6of h6formula h6will
h6compound h6the h6problem h6because h6the h6baby h6will h6not h6be h6hungry h6and h6will h6not
h6empty h6the h6breasts h6well.
Incorrect: h6Applying h6lotion h6to h6the h6nipples h6is h6not h6effective h6for h6keeping h6them h6soft.
h6Excessiveamou h6nts h6of h6lotion h6may7harbor h6microorganisms.
, Correct: h6In h6order h6to h6stimulate h6adequate h6milk h6production, h6the h6breasts h6should h6be
h6pumped h6ift h6he h6infant7is h6not h6sucking h6or7eating h6well, h6or h6if h6the h6breasts h6are h6not
h6fully h6emptied.
Incorrect: h6Using h6soap h6on h6the h6breasts h6dries h6the h6nipples h6and h6can h6cause
h6 crackin h6g.The h6baby h6should h6be h6given h6a h6bottle h6of h6formula h6if
h6 engorgement h6occurs.
The h6nipples h6should h6be h6covered h6with h6lotion h6when h6the h6baby h6is
h6 not h6nursin h6g.The h6breasts h6should h6be h6pumped h6if h6the h6baby h6is
h6 not h6sucking h6adequately. h6The h6breasts h6should h6be h6washed h6with
h6 soap h6and h6water h6once h6per7day.
5. A h6client h6in h6preterm h6labor7is h6admitted h6to h6the h6hospital. h6Which h6classification h6of
h6drugs h6should h6t h6henurse h6anticipate h6administering?
Correct: h6Tocolytics h6are h6used h6to h6stop h6labor. h6One h6of h6the h6most h6commonly h6used
h6tocolytic h6drug h6sis h6ritodrine h6(Yutopar).
Incorrect: h6Anticonvulsants h6are h6used h6for7clients h6with
h6pregnancy- h6induced h6hypertension h6who h6arelikely h6to h6seize.
Incorrect: h6The h6glucocorticoids h6(e.g., h6betamethasone h6and h6dexamethasone) h6are h6used h6for
h6accelerat h6ing h6fetal h6lung h6maturation h6and h6production h6of h6surfactant. h6They h6are h6commonly
h6used h6if h6themembran h6es h6are h6ruptured h6or h6labor h6cannot h6be h6stopped.
Incorrect: h6Anti-
infective h6are h6used h6if h6there h6is h6infection. h6Preterm h6labor h6may h6or7may7not h6involveruptured
h6membranes h6with h6its h6accompanying h6risk h6of h6infection.
Tocolytics
h6 Anti
h6 convulsantsGl
u
h6cocorticoidsA
nt h6i-infective
6. Which h6of h6the h6following h6 are h6probable h6 signs, h6 strongly h6indicating h6pregnancy?
