Maternity ATI Proctored Exam Pack A+ Graded.

Maternity ATI Proctored Exam Pack A+ Graded. Obtaining a prescription for IV oxytocin is an action that the nurse should take for a client who requires labor induction and augmentation. Administer methylergonovine. Administering methylergonovine is an action that the nurse should take for a client who is experiencing postpartum hemorrhage. 17) A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect? (Select all that apply.) Yellow sclera Creases over two-thirds of the soles of the feet Posterior fontanel larger than the anterior fontanel Molding of the head Lanugo on the shoulders Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected clinical manifestation. Creases over two-thirds of the soles of the feet is correct. Fewer creases over the soles of the feet is an indication of prematurity. Creases over the entire soles of the feet is an indication of postmaturity. Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm. It is located on the top of the newborn's head and is larger than the posterior fontanel. Molding of the head is correct. Molding occurs during the birth process as the newborn travels through the birth canal, resulting in compression of the soft bones of the skull. Lanugo on the shoulders is correct. Absence of lanugo is an indication of postmaturity. Abundant lanugo is an indication of prematurity. 18) A nurse is developing an educational program for adolescents about nutrition during the third trimester of pregnancy. Which of the following statements should the nurse include in the program? "Consume three to four servings of dairy each day." Calcium intake is especially important during an adolescent's pregnancy because bone absorption of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume three to four servings of dairy per day to meet their calcium needs. "Increase your daily caloric intake by 600 to 700 calories." Consuming an additional 600 to 700 cal per day could lead to excessive weight gain, which increases the adolescent's risk for complications related to pregnancy, labor, and delivery. The nurse should instruct the adolescents that, if they have a BMI within the expected reference range prior to pregnancy, they should increase their daily caloric intake by 340 cal in the first trimester and 452 cal in the second and third trimesters. "Limit your daily sodium intake to less than 1 gram." Sodium supports the increase in blood volume that occurs during pregnancy. An adequate sodium intake is approximately 1.5 g per day. The nurse should instruct the adolescents that an adequate intake of sodium is required during pregnancy. "Increase your protein intake to 40 to 50 grams each day." Adequate protein intake is necessary to support the rapid growth of the fetus, maternal tissues, increasing blood volume, and the formation of amniotic fluid. Therefore, the nurse should instruct the adolescents to increase their daily intake of protein to approximately 71 g during the second and third trimesters of pregnancy. 19) A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best nonpharmacological intervention to perform to relieve the client's discomfort? Back rub A back rub is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use. Counter-pressure According to evidence-based practice, counter-pressure is the best nonpharmacological technique to use when relieving the client's discomfort from the fetus being in a posterior position because this intervention lifts the fetal head off of the spinal nerve. Playing music Playing music is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use. Foot massage A foot massage is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use.  20) A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. MY ANSWER The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. Restrict the total hourly intake to 200 mL. The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema. Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate. Administer protamine sulfate for manifestations of toxicity. The nurse should administer calcium gluconate if the client shows manifestations of magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory depression, slurred speech, and cardiac arrest. 21)A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner. The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members. Repeat information to ensure client understanding. The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said. Listen to the client and her partner as they reflect upon the birth experience. Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new mother moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment. 22) A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? Apply a cool pack for 10 min to the heel prior to the puncture. A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a warm pack prior to the puncture. Request a prescription for IM analgesic. The pain experienced from a heel stick is too brief to warrant risking the adverse effects of parenteral analgesia. Use a manual lance blade to pierce the skin. A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that the depth of the puncture is not too deep, avoiding injury to the newborn. Place the newborn skin to skin on the mother's chest. Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure. 23) A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Moderate variability of the FHR Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid base balance. It is not a contraindication to the administration of oxytocin. Cessation of uterine dilation Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. Prolonged active phase of labor A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. 24) A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg A blood pressure of 136/88 mm Hg is within the expected reference range for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. Report of insomnia A regular occurrence of insomnia can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. 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 should be reported to the provider. Report of Braxton-Hicks contractions Braxton-Hicks contractions can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provide 25) A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature. The nurse should check the client's temperature to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention. Observe for uterine contractions. The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention. Administer Rho(D) immune globulin. The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention. Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. 26) A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? Place the client in a supine position for 30 min following the first dose of anesthetic solution. The nurse should plan to position the client upright in order to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution in order to decrease the maternal risk for hypotension. The nurse should not administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution. The nurse should not plan to restrict the client's intake prior to the epidural placement and the 27) A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? Insert the syringe tip before compressing the bulb. The client should compress the bulb before inserting the syringe tip. Compressing the bulb after it is in the newborn's nares or mouth could push the secretions and mucus further inside. Suction each of the nares before suctioning the mouth. The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. Insert the tip of the syringe into the center of the newborn's mouth. The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. 28) A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia? Hypertonia A newborn who has hypoglycemia can exhibit hypotonia. Increased feeding MY ANSWER A newborn who has hypoglycemia can exhibit poor feeding behaviors. Hyperthermia A newborn who has hypoglycemia can exhibit hypothermia. Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a clinical manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. 29) A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on his face Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth. This finding requires no treatment. A newborn who is 32 hr old and has not passed a meconium stool A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. A newborn who is 12 hr old and has pink-tinged urine Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. 30) A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)  Palpate the fundus to identify the fetal part.  Determine the location of the fetal back.  Palpate for the fetal part presenting at the inlet  Identify the attitude of the head. The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head. 31) A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? Perform Nitrazine testing. The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take. Assess the fluid. The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take. Check cervical dilation. The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take. Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. 32) A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? "I will eat foods that appeal to my taste instead of trying to balance my meals." Clients who have hyperemesis gravidarum should eat to taste to avoid nausea. "I will avoid having a snack at bedtime." Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. "I will have 8 ounces of hot tea with each meal." Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. "I will pair my sweets with a starch instead of eating them alone." Clients who have hyperemesis gravidarum should eat protein following a sweet snack. 33)A nurse is providing discharge teaching to a client who is postpartum. For which of the following clinical manifestations should the nurse instruct the client to monitor and report to the provider? Persistent abdominal striae Persistent abdominal striae are caused by the separation of the underlying connective tissue and are an expected postpartum finding. Temperature 37.8° C (100.2° F) The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because it could be an indication of infection. Unilateral breast pain Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider. Brownish-red discharge on day 5 Brownish-red discharge is an expected clinical manifestation during days 3 to 10. The client should report a large amount of lochia and large clots to the provider.