ATI Maternal Newborn Proctored EXAM QUESTIONS AND ANSWERS

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, to pinkish 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. a. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part b. Wrap the visible cord tightly with sterile, dry gauze c. Apply oxygen to the client at 2 L/min via nasal cannula d. Place the client in the lithotomy position and apply fundal pressure 8. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption? Which of the following laboratory tests should the nurse expect the provider to prescribe? a. Kleihauer-Betke test b. Progesterone serum level c. Lecithin/sphingomyelin (L/S) ration d. Maternal Alpha-fetoprotein (AFP) 9. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia 10. A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? a. 2+ deep tendon reflex b. Proteinuria of 200mg in a 24-hr specimen c. Polyuria d. Blurred vision 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? • Vraag 20 • • OT is een 44-jarige patiënt die zich presenteert voor evaluatie van plotselinge ernstige pijn in de bovenbuik. Ze is zich bewust van het begin, dat diep was en ongeveer een uur geleden gebeurde. Hij ontkent dat het begin iets te maken had met eten of eten, en hij ontkent misselijkheid of braken. Bij onderzoek ligt ze op haar rechterkant met heupen en knieën gebogen om de knieën naar de borst te trekken. De vitale functies zijn stabiel, maar onderzoek onthult onvrijwillige afscherming. De buik is zacht en trommelachtig voor percussie in alle kwadranten. CBC onthult een aantal witte bloedcellen van 15.600/µL. AGACNP vermoedt: • • A. Dissectie van het aorta-aneurysma. • B. acute pancreatitis • C. geperforeerde maagzweer • D. Mallory-Weiss traan