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VIRTUAL ATI- maternal newborn ASSESSMENT updated version 2024/2025

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VIRTUAL ATI- maternal newborn ASSESSMENT updated version 2024/2025 A nurse is planning to administer phytonadione IM to a newborn shortly after birth. The nurse should identify that this medication is administered to prevent which of the following complications? 1. Ophthalmia neonatorum 2. Hemorrhagic disease 3. Hypoglycemia 4. Hypothermia - CORRECT ANSWER 2. Hemorrhagic disease A nurse is assisting with the care of a client who is in active labor and noted late deceleration in the fetal heart rate. Which of the following actions should the nurse take first? 1. Palpate the client's uterus to check for tachysystole 2. Place the client in a side-lying position 3. Administer oxygen at 10 L/min via nonrebreather face mask 4. Increase the rate of the clients IV fluids - CORRECT ANSWER 2. Place the client in a side-lying position A nurse is an antepartum clinic is collecting data from a client who is 28 weeks’ gestation. Which of the following findings should the nurse identify as an indication of a potential complication? 1. Fetal heart rate 120/min 2. Dysuria 3. Leucorrhea 4. Fasting blood glucose 80 mg/dL - CORRECT ANSWER 2. Dysuria -unexpected finding that can indicate a UTI A nurse is assisting with the care of a client who is in active stage of labor. For which of the following findings should the nurse notify the provider? 1. Spontaneous rupture of membranes 2. prolapsed umbilical cord 3. Pink to blood mucus discharge 4. Contraction duration of 60 seconds - CORRECT ANSWER 2. prolapsed umbilical cord A nurse on a postpartum unit is reinforcing teaching with an AP about preventing newborn abduction. Which of the following information should the nurse include? 1. The AP should use the identification card on the crib to confirm the newborn's identity 2. The AP should allow the newborn to remain in the mother’s room while showering 3. The AP should carry the newborn to the nursery 4. The AP should have their photo identification badge displayed - CORRECT ANSWER 4. The AP should have their photo identification badge displayed A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian demonstrates an understanding of the teaching? 1. "I will place my baby at a 45-degree angle in the car seat" 2. "I will position the harness retainer clip across my baby’s stomach" 3. "I will keep my baby’s car seat rear facing until she weighs 20lb and is 1 year" 4. "I will place padding under my baby’s back until she reaches 10 lbs." - CORRECT ANSWER 1. "I will place my baby at a 45-degree angle in the car seat" A nurse is collecting data from a client who has hyperemesis gravid arum. Which of the following findings indicates that the client is at risk for dehydration? 1. Hematuria 2. Sodium 140 mEq/L 3. Potassium 3.5 mEq/L 4. Ketonuria - CORRECT ANSWER 4. Ketonuria A nurse is caring for a postpartum client who has an episiotomy. Which of the following actions should the nurse take? 1. Apply an anesthetic spray to the client's perineal area as needed for pain 2. Place a donut pillow under the clients when sitting in a chair 3. Apply a moist heat pack to the client's perineal area for 20 min every hour for the first 24 hours 4. Assist the client with changing the perineal pad every 8 hr to expedite healing - CORRECT ANSWER 1. Apply an anesthetic spray to the client's perineal area as needed for pain A nurse is caring for a client who is 16 weeks of gestation and is at risk for developing hyperemesis gravid arum. Which of the following conditions places the client at an increased risk of developing this condition? 1. Placenta Previa 2. Hypertension 3. Iron deficiency anemia 4. Diabetes mellitus - CORRECT ANSWER 4. Diabetes mellitus A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements should the nurse include in the teaching? 1. "You should keep the water temp at 110 degrees Fahrenheit for your baby’s bath"

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Uploaded on
October 29, 2024
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Written in
2024/2025
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hredu82 ASSIGNMENT 4-
2024/2025 with elaborated
questions and answers
A client develops internal bleeding after abdominal surgery. Which signs and symptoms
of hemorrhage should the nurse expect the client to exhibit? Select all that apply.
1
Pallor
2
Polyuria
3
Bradypnea
4
Tachycardia
5
Hypertension - CORRECT ANSWER 1, 4

What is the term for shock associated with a ruptured abdominal aneurysm?
1
Vasogenic shock
2
Neurogenic shock
3
Cardiogenic shock
4
Hypovolemic shock - CORRECT ANSWER 4

A client who has peripheral arterial disease of the lower extremities tells the nurse, "I
walk so slowly that no one wants to walk with me." What is the best response by the
nurse?
1
"A vascular rehabilitation program may help you."
2
"You should be sitting with your feet elevated, not walking."
3
"Try again tomorrow because maybe you will have a better day."
4
"They are not good friends if they are not willing to walk with you." - CORRECT
ANSWER 1

,The nurse notes asystole on the cardiac monitor. Which action should the nurse take
immediately?
1
Defibrillate
2
Assess the client's pulse
3
Initiate advanced cardiac life support
4
Check another lead to confirm asystole - CORRECT ANSWER 2

One week after admission to the cardiac care unit, a client displays an outburst of anger
and tells the nurse to get out of the room. Which is the most appropriate nursing action?
1
Administer the prescribed sedative.
2
Return when the client has calmed down.
3
Point out that this behavior is inappropriate.
4
Notify the primary healthcare provider of the client's behavior. - CORRECT ANSWER 2

Which clinical indicator is the nurse most likely to identify when completing a history and
physical assessment of a client with complete heart block?
1
Syncope
2
Headache
3
Tachycardia
4
Hemiparesis - CORRECT ANSWER 1

The family of a client with right ventricular heart failure expresses concern about the
client's increasing abdominal girth. What physiologic change should the nurse consider
when explaining the client's condition?
1
Loss of cellular constituents in blood
2
Rapid osmosis from tissue spaces to cells
3
Increased pressure within the circulatory system
4
Rapid diffusion of solutes and solvents into plasma - CORRECT ANSWER 3

, A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's
cardiac monitor. What intervention is the priority?
1
Elective cardioversion
2
Immediate defibrillation
3
An intramuscular (IM) injection of digoxin
4
An intravenous (IV) line for emergency medications - CORRECT ANSWER 2

A nurse is caring for a client who was admitted to the hospital with a diagnosis of
chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal
cannula. What is the primary focus of therapy when caring for this client?
1
Limiting hydration
2
Improving ventilation
3
Decreasing exogenous oxygen
4
Correcting the bicarbonate deficit - CORRECT ANSWER 2

A client with a history of rheumatic fever and a heart murmur reports gaining weight in
spite of nausea and anorexia. The client also reports shortness of breath several times
each day and when performing minor tasks. Which additional information should the
nurse obtain?
1
Retrospective 24-hour calorie count
2
Elimination pattern during the last 30 days
3
Complete gynecological and sexual history
4
Presence of a cough and pulmonary secretions - CORRECT ANSWER 4

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a
common early sign of laryngeal cancer for which the nurse should assess in this client?
1
Aphasia
2
Dyspnea
3
Dysphagia
4
Hoarseness - CORRECT ANSWER 4
R321,57
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