VATI RN Maternal Newborn Assessment Test with Verified
Answers Rated A
A charge nurse is teaching a newly licensed findings should the nurse withhold the
nurse about substance use disorders during medication? - ANSWER -Heart rate 54/min
pregnancy. Which of the following statements by -The nurse should identify that a heart rate of
the newly licensed nurse indicates an 54/min is below the expected reference range of
understanding of the teaching? - 60 to 100/min. During pregnancy, the heart rate
ANSWER -Encourage client who are increases 10 to 15/min due to increased blood
prescribed methadone to breastfeed. volume and increase tissue demands for oxygen.
-The nurse should encourage clients who are Bradycardia is a contraindication for the
prescribed methadone during pregnancy to administration of labetalol, an antihypertensive
breastfeed their newborns to help with medication. Therefore, the nurse should withhold
withdrawal symptoms. the medication and notify the provider.
A nurse is caring for a client who received A nurse is caring for a client who is at 30 weeks
terbutaline subcutaneously. Which of the of gestation and observes the client choking
following findings is an indication the medication while eating lunch. The client is unable to speak
was effective? - ANSWER -Decreased or cough. Identify the sequence of steps the
frequency of contractions. nurse should take to clear the airway obstruction.
-Terbutaline is a tocolytic medication that is used - ANSWER -1. Stand posterior to the client.
to halt preterm labor. Terbutaline cause 2. Position arms under the client's axilla and
relaxation of smooth muscle, which decrease across the client's chest.
uterine activity. Therefore, the nurse should 3. Place thumb-side of a clenched fist to the
identify that a decrease in frequency of client's mid-sternum area.
contractions is an indication that terbutaline was 4. Initiate chest thrust to the client using a
effective. backward motion.
-If the client becomes unconscious, the nurse
should perform CPR and activate emergency
A charge nurse is discussing care of clients who medical services.
are in labor with a newly licensed nurse. Which
of the following actions should the charge nurse
include in the teaching regarding situations A nurse is preparing to administer an opioid
requiring an amniotomy? - ANSWER - analgesic to a client who is in active labor. Which
Placing a fetal scalp electrode. of the following assessments should the nurse
-A fetal scalp electrode is attached to the perform? (SATA) - ANSWER -Maternal
presenting part of the fetus in order to provide blood pressure.
accurate continuous monitoring of the fetal heart -Opioid analgesic can cause hypotension. The
rate. If the client's membranes are intact, the nurse should assess the clients blood pressure
amniotic sac must be artificially ruptured prior to before and after administering opioids.
attaching the electrode to enable access to the Pain level.
presenting part. -The nurse should assess the clients baseline
pain level prior to administering pain medication
and again after administering pain medication to
A nurse is reviewing the medical record of a determine the effectiveness of the medication.
client who has preeclampsia prior to Opioid analgesic are indicated for the relief of
administering labetalol. For which of the following moderate to sever labor pain.
, VATI RN Maternal Newborn Assessment Test with Verified
Answers Rated A
Fetal heart rate. mm Hg.
-Opioid analgesics can cause fetal bradycardia - The nurse should identify that an MVU of 220
and changes in variability. The nurse should mm Hg is within the expected range during the
assess the fetal heart rate prior to administering active phase of labor. MVUs generally range
an opioid analgesic to ensure the rate is within between 100 to 250 mm Hg during the first stage
the expedited reference range and to have a of labor and increase to 300 to 400 mm Hg
baseline for future assessments. The nurse during the second stage of labor. MVUs are
should provide ongoing assessments of fetal calculated by subtracting the baseline uterine
heart rate throughout labor according to facility pressure from the peak contraction pressure for
protocol. every contraction that occurs during a 10-min
period. The nurse then adds the pressure
produced by each contraction during that time to
A nurse is reviewing the medical records of a determine the MVUs.
client who is at 8 wks. of gestation. Which of the
following findings should the nurse identify as a
risk factor for developing preeclampsia? - A nurse is assessing a client who has just
ANSWER -Rheumatoid Arthritis. undergone a cesarean birth and was given
-The presence of a connective tissue disease, epidural morphine for postpartum pain relief 1hr
such as rheumatoid arthritis or systemic lupus ago. The nurse notes that the clients respiratory
erythematosus, increase a clients risk for rate is 10/min. Which of the following actions
developing preeclampsia. should the nurse take first? - ANSWER -
Administer oxygen by nonrebreather face mask.
-The first action the nurse should take when
A nurse is reviewing the laboratory results for a using the airway, breathing, circulation approach
postpartum client who is receiving warfarin for to client care is to administer oxygen by
deep-vein thrombosis. Which of the following nonrebreather mask to treat manifestations of
laboratory tests should the nurse monitor? - respiratory depression due to morphine
ANSWER -International normalized ratio administration.
(INR).
-The nurse should monitor the INR of a client
who is taking warfarin. Prothrombin time(PT) is A nurse is assessing a client who has placenta
also measure to regulate warfarin therapy. previa and is receiving fetal monitoring. Which of
However, PT values are more difficult to the following clinical findings should the nurse
interpret. INR determined by multiplying the PT expect? - ANSWER -Painless vaginal
by a correction factor based on the specific bleeding.
thromboplastin preparation used for the test, as a -The placenta implants in the lower uterine
way of equalizing laboratory to laboratory segment, partially or completely covering the
variations. cervix. With cervical changes, the placental blood
vessels can tear, which results in bleeding.
A nurse is monitoring a client who is in the active
phase of labor and has an intrauterine pressure A nurse is assessing a client who is at 33wks of
catheter and fetal scalp electrode. Which of the gestation. Which of the following findings should
following findings should the nurse expect? - the nurse report to the provider? -
ANSWER -Montevideo units (MVU) of 220 ANSWER -Episodes of blurred vision.
Answers Rated A
A charge nurse is teaching a newly licensed findings should the nurse withhold the
nurse about substance use disorders during medication? - ANSWER -Heart rate 54/min
pregnancy. Which of the following statements by -The nurse should identify that a heart rate of
the newly licensed nurse indicates an 54/min is below the expected reference range of
understanding of the teaching? - 60 to 100/min. During pregnancy, the heart rate
ANSWER -Encourage client who are increases 10 to 15/min due to increased blood
prescribed methadone to breastfeed. volume and increase tissue demands for oxygen.
-The nurse should encourage clients who are Bradycardia is a contraindication for the
prescribed methadone during pregnancy to administration of labetalol, an antihypertensive
breastfeed their newborns to help with medication. Therefore, the nurse should withhold
withdrawal symptoms. the medication and notify the provider.
A nurse is caring for a client who received A nurse is caring for a client who is at 30 weeks
terbutaline subcutaneously. Which of the of gestation and observes the client choking
following findings is an indication the medication while eating lunch. The client is unable to speak
was effective? - ANSWER -Decreased or cough. Identify the sequence of steps the
frequency of contractions. nurse should take to clear the airway obstruction.
-Terbutaline is a tocolytic medication that is used - ANSWER -1. Stand posterior to the client.
to halt preterm labor. Terbutaline cause 2. Position arms under the client's axilla and
relaxation of smooth muscle, which decrease across the client's chest.
uterine activity. Therefore, the nurse should 3. Place thumb-side of a clenched fist to the
identify that a decrease in frequency of client's mid-sternum area.
contractions is an indication that terbutaline was 4. Initiate chest thrust to the client using a
effective. backward motion.
-If the client becomes unconscious, the nurse
should perform CPR and activate emergency
A charge nurse is discussing care of clients who medical services.
are in labor with a newly licensed nurse. Which
of the following actions should the charge nurse
include in the teaching regarding situations A nurse is preparing to administer an opioid
requiring an amniotomy? - ANSWER - analgesic to a client who is in active labor. Which
Placing a fetal scalp electrode. of the following assessments should the nurse
-A fetal scalp electrode is attached to the perform? (SATA) - ANSWER -Maternal
presenting part of the fetus in order to provide blood pressure.
accurate continuous monitoring of the fetal heart -Opioid analgesic can cause hypotension. The
rate. If the client's membranes are intact, the nurse should assess the clients blood pressure
amniotic sac must be artificially ruptured prior to before and after administering opioids.
attaching the electrode to enable access to the Pain level.
presenting part. -The nurse should assess the clients baseline
pain level prior to administering pain medication
and again after administering pain medication to
A nurse is reviewing the medical record of a determine the effectiveness of the medication.
client who has preeclampsia prior to Opioid analgesic are indicated for the relief of
administering labetalol. For which of the following moderate to sever labor pain.
, VATI RN Maternal Newborn Assessment Test with Verified
Answers Rated A
Fetal heart rate. mm Hg.
-Opioid analgesics can cause fetal bradycardia - The nurse should identify that an MVU of 220
and changes in variability. The nurse should mm Hg is within the expected range during the
assess the fetal heart rate prior to administering active phase of labor. MVUs generally range
an opioid analgesic to ensure the rate is within between 100 to 250 mm Hg during the first stage
the expedited reference range and to have a of labor and increase to 300 to 400 mm Hg
baseline for future assessments. The nurse during the second stage of labor. MVUs are
should provide ongoing assessments of fetal calculated by subtracting the baseline uterine
heart rate throughout labor according to facility pressure from the peak contraction pressure for
protocol. every contraction that occurs during a 10-min
period. The nurse then adds the pressure
produced by each contraction during that time to
A nurse is reviewing the medical records of a determine the MVUs.
client who is at 8 wks. of gestation. Which of the
following findings should the nurse identify as a
risk factor for developing preeclampsia? - A nurse is assessing a client who has just
ANSWER -Rheumatoid Arthritis. undergone a cesarean birth and was given
-The presence of a connective tissue disease, epidural morphine for postpartum pain relief 1hr
such as rheumatoid arthritis or systemic lupus ago. The nurse notes that the clients respiratory
erythematosus, increase a clients risk for rate is 10/min. Which of the following actions
developing preeclampsia. should the nurse take first? - ANSWER -
Administer oxygen by nonrebreather face mask.
-The first action the nurse should take when
A nurse is reviewing the laboratory results for a using the airway, breathing, circulation approach
postpartum client who is receiving warfarin for to client care is to administer oxygen by
deep-vein thrombosis. Which of the following nonrebreather mask to treat manifestations of
laboratory tests should the nurse monitor? - respiratory depression due to morphine
ANSWER -International normalized ratio administration.
(INR).
-The nurse should monitor the INR of a client
who is taking warfarin. Prothrombin time(PT) is A nurse is assessing a client who has placenta
also measure to regulate warfarin therapy. previa and is receiving fetal monitoring. Which of
However, PT values are more difficult to the following clinical findings should the nurse
interpret. INR determined by multiplying the PT expect? - ANSWER -Painless vaginal
by a correction factor based on the specific bleeding.
thromboplastin preparation used for the test, as a -The placenta implants in the lower uterine
way of equalizing laboratory to laboratory segment, partially or completely covering the
variations. cervix. With cervical changes, the placental blood
vessels can tear, which results in bleeding.
A nurse is monitoring a client who is in the active
phase of labor and has an intrauterine pressure A nurse is assessing a client who is at 33wks of
catheter and fetal scalp electrode. Which of the gestation. Which of the following findings should
following findings should the nurse expect? - the nurse report to the provider? -
ANSWER -Montevideo units (MVU) of 220 ANSWER -Episodes of blurred vision.
