ATI MATERNAL NEWBORN PROCTORED EXAM VERSION 1 AND VERSION 2 UPDATED 2022/2023 LATEST UPDATE

ATI MATERNAL NEWBORN PROCTORED EXAM VERSION 1 AND VERSION 2 UPDATED 2022/2023 LATEST UPDATE A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "The circumcision will heal completely within a couple of weeks." d. "I can give him a tub bath in two days." d. "I can give him a tub bath in two days." The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks. A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner will put the condom on while his penis is erect." b. "I will remove the condom 30 minutes after intercourse." c. "My partner should leave an empty space at the tip." d. "I can use spermicidal gels or creams to increase effectiveness." b. "I will remove the condom 30 minutes after intercourse." To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina. A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "What happens to your contractions when you move about?" d. "Have you felt fetal movement over the last 24 hours?" b. "Have you noticed any bloody show or fluid coming from your vagina?" 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1−3, to lochia serosa (pinkish brown) on days 4−9, to lochia alba (creamy white) days 10−21. Incorrect: Numerous clots are abnormal and should be reported to the physician. Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1−3, to lochia serosa (pinkish brown) on days 4−9, to lochia alba (creamy white) days 10−21. Incorrect: Numerous clots are abnormal and should be reported to the physician. Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. Correct: Lochia normally lasts for about 21 days, and changes from a bright red, topinkish brown, to creamy white. The color of the lochia changes from a bright red to white after four days Numerous large clots are normal for the next three to four days Saturation of the perineal pad with blood is expected when getting up from the bed Lochia should last for about 3 weeks, changing color every few days 2. A nurse monitors fetal well−being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. Incorrect: Variable decelerations (not late decelerations) are associated with cord compression. Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. Correct: Late decelerations are associated with uteroplacental insufficiency and are a signof fetal hypoxia. Repeated late decelerations indicate fetal distress. The umbilical cord is wrapped tightly around the fetus' neck The fetal cord is being compressed due to rapid descent of the fetal head Maternal contractions are not adequate enough to deliver the fetus The fetus is not receiving adequate oxygen and is in distress 3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth? Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions. Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions. Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of theclient and the family will be high. Inserting an indwelling catheter helps to keep thebladder empty and free from injury when the incision is made. Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case. Monitor oxygen saturation and administer pain medication. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter. Perform a sterile vaginal examination and assess breath sounds. A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "The circumcision will heal completely within a couple of weeks." d. "I can give him a tub bath in two days." d. "I can give him a tub bath in two days." The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks. A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner will put the condom on while his penis is erect." b. "I will remove the condom 30 minutes after intercourse." c. "My partner should leave an empty space at the tip." d. "I can use spermicidal gels or creams to increase effectiveness." b. "I will remove the condom 30 minutes after intercourse." To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina. A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "What happens to your contractions when you move about?" d. "Have you felt fetal movement over the last 24 hours?" b. "Have you noticed any bloody show or fluid coming from your vagina?" Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Telling the client to walk is not a correct response because it is an intervention rather than an assessment question. The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? Select one: a. The purpose of the NST is to assess the fetal CNS. b. The purpose of the NST helps to determine gestational age. c. The purpose of the NST is to determine fetal lie. d. The purpose of the NST is to determine fetal breathing. a. The purpose of the NST is to assess the fetal CNS. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? A) Acrocyanosis B) Transient strabismus C) Jaundice D) Caput succedaneum - c) jaundice A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor ( SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? A) Large for gestational age B) Hyperglycemia C) Bradypnea D) Vomiting - D) Vomiting A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain ? A) Decreased heart rate B) Chin quivering C) Pinpoint pupils D) Slowed respirations - B) Chin quivering A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? ( Use all the steps and list them in order) A) Clean the newborn's diaper area B) Wash the newborn's neck by lifting the newborn's chin. C) Wipe the newborn's eyes from the inner canthus outward. D) Cleanse the skin around the newborn's umbilical cord stump. E) Wash the newborn's legs and feet. - C,B,D,E,A A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? A) swelling of the face B) varicose veins in the calves