OB Ati Study Guide Questions Review with Complete
Solutions
A nurse is caring for a client who is to receive pregnant and has gonorrhea is at an increased
oxytocin to augment her labor. Which of the risk for premature rupture of membranes,
following findings contraindicates the initiation of chorioamnionitis, preterm birth, neonatal sepsis,
the oxytocin infusion and should be reported to and intrauterine growth restriction.
the provider?
Excessive bleeding
Late decelerations - A client who is pregnant and has gonorrhea is
Moderate variability of the FHR not at an increased risk for excessive bleeding.
Cessation of uterine dilation
Prolonged active phase of labor - -ANS: Oligohydramnios
Late decelerations - A client who is pregnant and has gonorrhea is
- indicative of uteroplacental insufficiency. not at an increased risk for oligohydramnios.
Therefore, this is a contraindication for the Oligohydramnios is a decrease in amniotic fluid
administration of oxytocin and should be and is associated with congenital anomalies such
reported to the provider. as renal agenesis and intrauterine growth
restriction.
Moderate variability of the FHR
- an expected assessment finding associated Proteinuria
with normal fetal acid-base balance. It is not a - A client who is pregnant and has gonorrhea is
contraindication to the administration of oxytocin. not at an increased risk for proteinuria.
Proteinuria is associated with preeclampsia.
Cessation of uterine dilation
- an indication for the initiation of an oxytocin
infusion to augment the client's labor
progression. Nurse is performing a vag exam on a patient who
is in labor and observes the umbilical cord
Prolonged active phase of labor protruding from the vagina. After calling for
- an indication for the initiation of an oxytocin assistance, which actions should the nurse take?
infusion to augment the client's labor
progression. -Insert two gloved fingers into the vagina and
apply upward pressure to the presenting part.
-Wrap the visible cord tightly with sterile, dry
gauze.
A nurse is caring for a patient that's 32 weeks -Apply oxygen to the client at 2 L/min via nasal
gestation and has gonorrhea. The nurse should cannula.
identify that the client is at an increased risk for -Place the client in the lithotomy position and
which of the following complications? apply fundal pressure. - -ANS: Insert two
gloved fingers into the vagina and apply upward
Excessive bleeding pressure to the presenting part.
Oligohydramnios - The nurse should quickly apply gloves and
Premature ROM insert two fingers into the vagina toward the
Proteinuria - -ANS: Premature rupture of cervix, exerting upward pressure onto the
membranes presenting part to relieve umbilical cord
- The nurse should identify that a client who is compression and increase oxygenation to the
,OB Ati Study Guide Questions Review with Complete
Solutions
fetus. complete."
- The nurse should instruct the client that the
Wrap the visible cord tightly with sterile, dry nonstress will take approximately 20 to 30 min,
gauze. but more time might be required if the fetus is in a
- The nurse should wrap the visible cord with a sleep state when the testing begins.
loose sterile towel saturated with warm 0.9%
sodium chloride solution, rather than with sterile, "You will lay in a supine position throughout the
dry gauze. test."
- The nurse should instruct the client to be
Apply oxygen to the client at 2 L/min via nasal positioned in a reclining chair or semi-Fowler's
cannula. position with a slight lateral tilt to ensure optimal
- The nurse should apply oxygen to the client at uterine perfusion.
8 to 10 L/min via nonbreather mask.
"You should not eat or drink for 2 hours before
Place the client in the lithotomy position and the test."
apply fundal pressure. - The client is not required to be NPO before or
- The nurse should place the client into a during the procedure. The nurse can suggest the
modified Sims position, knee-chest position, or client drink orange juice to increase her blood
extreme Trendelenburg to attempt to relieve the glucose level which will stimulate fetal
compression of the umbilical cord. movements.
Nurse is teaching patient of 37 weeks gestation A charge nurse on a labor and delivery unit is
and has a prescription for a nonstress test. teaching a newly licensed nurse how to perform
Which instructions should the nurse include? leopold maneuvers. Which images indicates the
first step of leopold maneuvers? - -ANS:
-Test should take 10-15 min to complete 1st - During this step, the nurse palpates the
-You will lay in supine position throughout the client's abdomen with the palms to determine
test which fetal part is in the uterine fundus. This step
-You should not eat or drink for 2 hours before also identifies the lie (transverse or longitudinal)
the test and presentation (cephalic or breech) of the
-You should press the handheld button when you fetus.
feel your baby move - -ANS: "You should
press the handheld button when you feel your 2nd step of Leopold maneuvers:
baby move." - During this step, the nurse uses the palms of
- The nurse should instruct the client to press the the hands to determine the location of the smooth
handheld button when the fetus moves. This fetal back and the irregularly shaped, smaller
action will mark the fetal monitor tracing with the fetal parts.
client's reports of fetal movement. This will assist
in the interpretation of the nonstress test to 3rd step of Leopold maneuvers:
determine if it is reactive or nonreactive. - During this step, the nurse determines which
fetal part is presenting in the pelvic inlet. The
The test should take 10 to 15 minutes to nurse gently grasps the lower uterine segment
, OB Ati Study Guide Questions Review with Complete
Solutions
between the thumb and forefingers, pressing in Nurse is assessing a patient that's 38 weeks
slightly. gestation during weekly prenatal visit. Which
findings should the nurse report to HCP?
4th step of Leopold maneuvers:
- During this step, the nurse faces the client's Blood pressure 136/88 mm Hg
feet and uses the fingertips to palpate the Report of insomnia
cephalic prominence. This assessment allows Weight gain of 2.2 kg (4.8 lb)
the nurse to determine the attitude of the fetal Report of Braxton Hicks contractions - -
head. ANS: Weight gain of 2.2 kg (4.8 lb):
- A weight gain of 2.2 kg (4.8 lb) in a week is
above the expected reference range and could
indicate complications. Therefore, this finding
Nurse in a provider's office is reviewing the should be reported to the provider.
medical record of a client who is in the 1st
trimester of pregnancy. Which findings should Blood pressure 136/88 mm HgA:
the nurse identify as a risk factor for development - Is within the expected reference range for a
of preeclampsia? client who is at 38 weeks of gestation. Therefore,
this finding does not need to be reported to the
Singleton pregnancy provider.
BMI of 20
Maternal age 32 years Report of insomnia:
Pregestational DM - -ANS: Pregestational - A regular occurrence of insomnia can be
diabetes mellitus expected for a client who is at 38 weeks of
- increases a client's risk for the development of gestation. Therefore, this finding does not need
preeclampsia. Other risk factors include to be reported to the provider.
preexisting hypertension, renal disease, systemic
lupus erythematosus, and rheumatoid arthritis. Report of Braxton Hicks contractions:
- Can be expected for a client who is at 38 weeks
Singleton pregnancy: of gestation. Therefore, this finding does not
- Multifetal gestation, rather than a single fetus need to be reported to the provider.
pregnancy, increases a client's risk for the
development of preeclampsia.
BMI of 20 Nurse performing physical assessment of a
- Having a BMI greater than 30 increases a newborn upon admission to nursery. Which
client's risk for the development of preeclampsia. manifestations should the nurse expect? (SATA)
Maternal age 32 years: Yellow sclera
A maternal age of younger than 19 or older than Acrocyanosis
40 increases the client's risk for the development Posterior fontanel larger than the anterior
of preeclampsia. fontanel
Positive Babinski reflex
Two umbilical arteries visible - -
Acrocyanosis is correct. - an expected finding for
Solutions
A nurse is caring for a client who is to receive pregnant and has gonorrhea is at an increased
oxytocin to augment her labor. Which of the risk for premature rupture of membranes,
following findings contraindicates the initiation of chorioamnionitis, preterm birth, neonatal sepsis,
the oxytocin infusion and should be reported to and intrauterine growth restriction.
the provider?
Excessive bleeding
Late decelerations - A client who is pregnant and has gonorrhea is
Moderate variability of the FHR not at an increased risk for excessive bleeding.
Cessation of uterine dilation
Prolonged active phase of labor - -ANS: Oligohydramnios
Late decelerations - A client who is pregnant and has gonorrhea is
- indicative of uteroplacental insufficiency. not at an increased risk for oligohydramnios.
Therefore, this is a contraindication for the Oligohydramnios is a decrease in amniotic fluid
administration of oxytocin and should be and is associated with congenital anomalies such
reported to the provider. as renal agenesis and intrauterine growth
restriction.
Moderate variability of the FHR
- an expected assessment finding associated Proteinuria
with normal fetal acid-base balance. It is not a - A client who is pregnant and has gonorrhea is
contraindication to the administration of oxytocin. not at an increased risk for proteinuria.
Proteinuria is associated with preeclampsia.
Cessation of uterine dilation
- an indication for the initiation of an oxytocin
infusion to augment the client's labor
progression. Nurse is performing a vag exam on a patient who
is in labor and observes the umbilical cord
Prolonged active phase of labor protruding from the vagina. After calling for
- an indication for the initiation of an oxytocin assistance, which actions should the nurse take?
infusion to augment the client's labor
progression. -Insert two gloved fingers into the vagina and
apply upward pressure to the presenting part.
-Wrap the visible cord tightly with sterile, dry
gauze.
A nurse is caring for a patient that's 32 weeks -Apply oxygen to the client at 2 L/min via nasal
gestation and has gonorrhea. The nurse should cannula.
identify that the client is at an increased risk for -Place the client in the lithotomy position and
which of the following complications? apply fundal pressure. - -ANS: Insert two
gloved fingers into the vagina and apply upward
Excessive bleeding pressure to the presenting part.
Oligohydramnios - The nurse should quickly apply gloves and
Premature ROM insert two fingers into the vagina toward the
Proteinuria - -ANS: Premature rupture of cervix, exerting upward pressure onto the
membranes presenting part to relieve umbilical cord
- The nurse should identify that a client who is compression and increase oxygenation to the
,OB Ati Study Guide Questions Review with Complete
Solutions
fetus. complete."
- The nurse should instruct the client that the
Wrap the visible cord tightly with sterile, dry nonstress will take approximately 20 to 30 min,
gauze. but more time might be required if the fetus is in a
- The nurse should wrap the visible cord with a sleep state when the testing begins.
loose sterile towel saturated with warm 0.9%
sodium chloride solution, rather than with sterile, "You will lay in a supine position throughout the
dry gauze. test."
- The nurse should instruct the client to be
Apply oxygen to the client at 2 L/min via nasal positioned in a reclining chair or semi-Fowler's
cannula. position with a slight lateral tilt to ensure optimal
- The nurse should apply oxygen to the client at uterine perfusion.
8 to 10 L/min via nonbreather mask.
"You should not eat or drink for 2 hours before
Place the client in the lithotomy position and the test."
apply fundal pressure. - The client is not required to be NPO before or
- The nurse should place the client into a during the procedure. The nurse can suggest the
modified Sims position, knee-chest position, or client drink orange juice to increase her blood
extreme Trendelenburg to attempt to relieve the glucose level which will stimulate fetal
compression of the umbilical cord. movements.
Nurse is teaching patient of 37 weeks gestation A charge nurse on a labor and delivery unit is
and has a prescription for a nonstress test. teaching a newly licensed nurse how to perform
Which instructions should the nurse include? leopold maneuvers. Which images indicates the
first step of leopold maneuvers? - -ANS:
-Test should take 10-15 min to complete 1st - During this step, the nurse palpates the
-You will lay in supine position throughout the client's abdomen with the palms to determine
test which fetal part is in the uterine fundus. This step
-You should not eat or drink for 2 hours before also identifies the lie (transverse or longitudinal)
the test and presentation (cephalic or breech) of the
-You should press the handheld button when you fetus.
feel your baby move - -ANS: "You should
press the handheld button when you feel your 2nd step of Leopold maneuvers:
baby move." - During this step, the nurse uses the palms of
- The nurse should instruct the client to press the the hands to determine the location of the smooth
handheld button when the fetus moves. This fetal back and the irregularly shaped, smaller
action will mark the fetal monitor tracing with the fetal parts.
client's reports of fetal movement. This will assist
in the interpretation of the nonstress test to 3rd step of Leopold maneuvers:
determine if it is reactive or nonreactive. - During this step, the nurse determines which
fetal part is presenting in the pelvic inlet. The
The test should take 10 to 15 minutes to nurse gently grasps the lower uterine segment
, OB Ati Study Guide Questions Review with Complete
Solutions
between the thumb and forefingers, pressing in Nurse is assessing a patient that's 38 weeks
slightly. gestation during weekly prenatal visit. Which
findings should the nurse report to HCP?
4th step of Leopold maneuvers:
- During this step, the nurse faces the client's Blood pressure 136/88 mm Hg
feet and uses the fingertips to palpate the Report of insomnia
cephalic prominence. This assessment allows Weight gain of 2.2 kg (4.8 lb)
the nurse to determine the attitude of the fetal Report of Braxton Hicks contractions - -
head. ANS: Weight gain of 2.2 kg (4.8 lb):
- A weight gain of 2.2 kg (4.8 lb) in a week is
above the expected reference range and could
indicate complications. Therefore, this finding
Nurse in a provider's office is reviewing the should be reported to the provider.
medical record of a client who is in the 1st
trimester of pregnancy. Which findings should Blood pressure 136/88 mm HgA:
the nurse identify as a risk factor for development - Is within the expected reference range for a
of preeclampsia? client who is at 38 weeks of gestation. Therefore,
this finding does not need to be reported to the
Singleton pregnancy provider.
BMI of 20
Maternal age 32 years Report of insomnia:
Pregestational DM - -ANS: Pregestational - A regular occurrence of insomnia can be
diabetes mellitus expected for a client who is at 38 weeks of
- increases a client's risk for the development of gestation. Therefore, this finding does not need
preeclampsia. Other risk factors include to be reported to the provider.
preexisting hypertension, renal disease, systemic
lupus erythematosus, and rheumatoid arthritis. Report of Braxton Hicks contractions:
- Can be expected for a client who is at 38 weeks
Singleton pregnancy: of gestation. Therefore, this finding does not
- Multifetal gestation, rather than a single fetus need to be reported to the provider.
pregnancy, increases a client's risk for the
development of preeclampsia.
BMI of 20 Nurse performing physical assessment of a
- Having a BMI greater than 30 increases a newborn upon admission to nursery. Which
client's risk for the development of preeclampsia. manifestations should the nurse expect? (SATA)
Maternal age 32 years: Yellow sclera
A maternal age of younger than 19 or older than Acrocyanosis
40 increases the client's risk for the development Posterior fontanel larger than the anterior
of preeclampsia. fontanel
Positive Babinski reflex
Two umbilical arteries visible - -
Acrocyanosis is correct. - an expected finding for
