VATI RN Maternal Newborn 2019
A charge nurse is teaching a newly licensed nurse about substance use disorders during
pregnancy. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? - ANSEncourage client who are prescribed methadone to
breastfeed.
-The nurse should encourage clients who are prescribed methadone during pregnancy to
breastfeed their newborns to help with withdrawal symptoms.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following
findings is an indication the medication was effective? - ANSDecreased frequency of
contractions.
-Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause
relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse should
identify that a decrease in frequency of contractions is an indication that terbutaline was
effective.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse.
Which of the following actions should the charge nurse include in the teaching regarding
situations requiring an amniotomy? - ANSPlacing a fetal scalp electrode.
-A fetal scalp electrode is attached to the presenting part of the fetus in order to provide
accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact,
the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access
to the presenting part.
A nurse is reviewing the medical record of a client who has preeclampsia prior to
administering labetalol. For which of the following findings should the nurse withhold the
medication? - ANSHeart rate 54/min
-The nurse should identify that a heart rate of 54/min is below the expected reference range
of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased
blood volume and increase tissue demands for oxygen. Bradycardia is a contraindication for
the administration of labetalol, an antihypertensive medication. Therefore, the nurse should
withhold the medication and notify the provider.
A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking
while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the
nurse should take to clear the airway obstruction. - ANS1. Stand posterior to the client.
2. Position arms under the client's axilla and across the client's chest.
3. Place thumb-side of a clenched fist to the client's mid-sternum area.
4. Initiate chest thrust to the client using a backward motion.
-If the client becomes unconscious, the nurse should perform CPR and activate emergency
medical services.
, A nurse is preparing to administer an opioid analgesic to a client who is in active labor.
Which of the following assessments should the nurse perform? (SATA) - ANSMaternal blood
pressure.
-Opioid analgesic can cause hypotension. The nurse should assess the clients blood
pressure before and after administering opioids.
Pain level.
-The nurse should assess the clients baseline pain level prior to administering pain
medication and again after administering pain medication to determine the effectiveness of
the medication. Opioid analgesic are indicated for the relief of moderate to sever labor pain.
Fetal heart rate.
-Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should
assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is
within the expedited reference range and to have a baseline for future assessments. The
nurse should provide ongoing assessments of fetal heart rate throughout labor according to
facility protocol.
A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of
the following findings should the nurse identify as a risk factor for developing preeclampsia?
- ANSRheumatoid Arthritis.
-The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus
erythematosus, increase a clients risk for developing preeclampsia.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin
for deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor? -
ANSInternational normalized ratio (INR).
-The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time(PT) is
also measure to regulate warfarin therapy. However, PT values are more difficult to interpret.
INR determined by multiplying the PT by a correction factor based on the specific
thromboplastin preparation used for the test, as a way of equalizing laboratory to laboratory
variations.
A nurse is monitoring a client who is in the active phase of labor and has an intrauterine
pressure catheter and fetal scalp electrode. Which of the following findings should the nurse
expect? - ANSMontevideo units (MVU) of 220 mm Hg.
- The nurse should identify that an MVU of 220 mm Hg is within the expected range during
the active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first
stage of labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs
are calculated by subtracting the baseline uterine pressure from the peak contraction
pressure for every contraction that occurs during a 10-min period. The nurse then adds the
pressure produced by each contraction during that time to determine the MVUs.
A nurse is assessing a client who has just undergone a cesarean birth and was given
epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients
respiratory rate is 10/min. Which of the following actions should the nurse take first? -
ANSAdminister oxygen by nonrebreather face mask.
-The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to administer oxygen by nonrebreather mask to treat
manifestations of respiratory depression due to morphine administration.
A charge nurse is teaching a newly licensed nurse about substance use disorders during
pregnancy. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? - ANSEncourage client who are prescribed methadone to
breastfeed.
-The nurse should encourage clients who are prescribed methadone during pregnancy to
breastfeed their newborns to help with withdrawal symptoms.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following
findings is an indication the medication was effective? - ANSDecreased frequency of
contractions.
-Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause
relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse should
identify that a decrease in frequency of contractions is an indication that terbutaline was
effective.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse.
Which of the following actions should the charge nurse include in the teaching regarding
situations requiring an amniotomy? - ANSPlacing a fetal scalp electrode.
-A fetal scalp electrode is attached to the presenting part of the fetus in order to provide
accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact,
the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access
to the presenting part.
A nurse is reviewing the medical record of a client who has preeclampsia prior to
administering labetalol. For which of the following findings should the nurse withhold the
medication? - ANSHeart rate 54/min
-The nurse should identify that a heart rate of 54/min is below the expected reference range
of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased
blood volume and increase tissue demands for oxygen. Bradycardia is a contraindication for
the administration of labetalol, an antihypertensive medication. Therefore, the nurse should
withhold the medication and notify the provider.
A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking
while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the
nurse should take to clear the airway obstruction. - ANS1. Stand posterior to the client.
2. Position arms under the client's axilla and across the client's chest.
3. Place thumb-side of a clenched fist to the client's mid-sternum area.
4. Initiate chest thrust to the client using a backward motion.
-If the client becomes unconscious, the nurse should perform CPR and activate emergency
medical services.
, A nurse is preparing to administer an opioid analgesic to a client who is in active labor.
Which of the following assessments should the nurse perform? (SATA) - ANSMaternal blood
pressure.
-Opioid analgesic can cause hypotension. The nurse should assess the clients blood
pressure before and after administering opioids.
Pain level.
-The nurse should assess the clients baseline pain level prior to administering pain
medication and again after administering pain medication to determine the effectiveness of
the medication. Opioid analgesic are indicated for the relief of moderate to sever labor pain.
Fetal heart rate.
-Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should
assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is
within the expedited reference range and to have a baseline for future assessments. The
nurse should provide ongoing assessments of fetal heart rate throughout labor according to
facility protocol.
A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of
the following findings should the nurse identify as a risk factor for developing preeclampsia?
- ANSRheumatoid Arthritis.
-The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus
erythematosus, increase a clients risk for developing preeclampsia.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin
for deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor? -
ANSInternational normalized ratio (INR).
-The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time(PT) is
also measure to regulate warfarin therapy. However, PT values are more difficult to interpret.
INR determined by multiplying the PT by a correction factor based on the specific
thromboplastin preparation used for the test, as a way of equalizing laboratory to laboratory
variations.
A nurse is monitoring a client who is in the active phase of labor and has an intrauterine
pressure catheter and fetal scalp electrode. Which of the following findings should the nurse
expect? - ANSMontevideo units (MVU) of 220 mm Hg.
- The nurse should identify that an MVU of 220 mm Hg is within the expected range during
the active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first
stage of labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs
are calculated by subtracting the baseline uterine pressure from the peak contraction
pressure for every contraction that occurs during a 10-min period. The nurse then adds the
pressure produced by each contraction during that time to determine the MVUs.
A nurse is assessing a client who has just undergone a cesarean birth and was given
epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients
respiratory rate is 10/min. Which of the following actions should the nurse take first? -
ANSAdminister oxygen by nonrebreather face mask.
-The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to administer oxygen by nonrebreather mask to treat
manifestations of respiratory depression due to morphine administration.
