m/b maternal newborn

50 ATI questions

1. A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?

A. Position the newborn at a 45-degree angle in the car seat

B. Place the retainer clip across the newborn's abdomen

C. Keep the car seat rear-facing until the newborn can sit unsupported

D. Place the shoulder harness straps below the level of the newborn's armpits

A

2. A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

A. There is an increased risk of introducing infection

B. This could initiate preterm labor

C. This could result in profound bleeding

D. There is an increased risk of rupture of membranes

C

3. A nurse caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

A. The client is not experiencing a rubella infection at this time

B. The client is immune to the rubella virus

C. The client requires a rubella vaccination at this time

D. The client requires a rubella vaccination following delivery

D

4. A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, lasting 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with a uniform deceleration beginning at the peak of the contraction and a return to baseline after the contractions is over. Which of the following actions should the nurse take?

A. Decrease the rate of infusion of the maintenance IV solution

B. Discontinue the infusion of the IV oxytocin

C. Increase the rate of infusion of the IV oxytocin

D. Slow the client's rate of breathing

B

5. A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15/min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make?

A. A negative test

B. A nonreactive test

C A positive test

D. A reactive test

B

6. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A. Administer vitamin K

B. Dry the skin

C. Administer eye prophylaxis

D. Place an identification bracelet

B

7. A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what APGAR score for this infant?

A. 6

B. 7

C. 8

D. 9

C

8. A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care (Select all that apply)

A. I'll expect the plastic ring to fall off by itself within a week

B. I'll apply petroleum jelly to his penis with diaper changes

C. I'll wash his penis with warm water and mild soap each day

D. I'll call the doctor if I see any bleeding

E. I'll make sure his diaper is loose in the front

A,D,E

9. A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

A. Hepatitis B immune globulin at 1 week followed by the hepatitis B vaccine monthly for 6 months

B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen

C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hrs of birth

D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

C

10. A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

A. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus.

B. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of fetal red blood cells.

C. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in the newborn.

D. The client has a history of receiving a transfusion with Rh-negative blood.

C

11. A nurse is caring for a client who has just delivered a newborn. The nurse note secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

A. Turn the newborn on his side

B. Use a suction catheter with low negative pressure

C. Suction the nose with a bulb syringe

D. Suction the mouth with a bulb syringe

D

12. A nurse is caring for a newborn 4 hrs after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A. Begin phototherapy

B. Suction excess mucus with a bulb syringe

C. Initiate early feeding

D. Prepare for an exchange blood transfusion

C

13. A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

A. Place the newborn under a radiant warmer

B. Obtain blood glucose by heel stick

C. Monitor the newborn's blood pressure

D. Initiate phototherapy

B

14. A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take?

A. Infuse a bolus of IV fluid

B. Administer Hydralazine 2.5 mg. IV

C. Prepare the client for immediate delivery

D. Administer betamethasone 12 mg. IM

D

15. A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

A. Administer prescribed analgesic medication

B. Encourage the client to rest between contractions

C. Massage the client's back

D. Turn the client onto her left side

C

16. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A. Cover the cord with a sterile, moist saline dressing

B. Prepare the client for an immediate birth

C. Place the client in knee-chest position

D. Insert a gloved hand into the vagina to relieve pressure on the cord

D

17. A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

A. A client who is experiencing fetal death at 32 weeks of gestation

B. A client who is experiencing preterm labor at 26 weeks of gestation

C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation

D. A client who has a post-term pregnancy at 42 weeks of gestation

B

18. A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?

A. Increase in blood pressure

B. Increase in lochia

C. Fundus firm to palpation

D. Report of absent breast pain

C

19. A nurse in a prenatal clinic is caring for a client. Using Leopold's maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A. Left Lower

B. Right Lower

C. Left Upper

D. Right Upper

D

20. A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.

B. Observe an area of redness on the breast of a client who is 1 day postpartum.

C. Monitor vital signs during admission of a client who has gestational hypertension.

D. Change the perineal pad of a client who just transferred from labor and delivery.

A

21. A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A. Orthostatic hypotension

B. Fundus palpable at the umbilicus

C. Urine output of 3,000 mL in 12 hr

D. Heart rate 110/min

D

22. A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?

A. Insert an indwelling urinary catheter

B. Administer oxytocin by continuous IV infusion

C. Tilt the client onto her right side with her legs elevated to at least 30 degrees

D. Massage the client's fundus to promote contractions

D

23. A nurse midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A. Report of pain above the umbilicus

B. Brownish vaginal discharge

C. Cervical dilation

D. Amniotic fluid in the vaginal vault

C

24. A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test?

A. This test assesses fetal lung maturity

B. This test assesses various markers of fetal well-being

C. This test identifies Rh incompatibility between the mother and fetus

D. This test is a screening test for neural tube defects in the fetus

D

25. A nurse is completing discharge instructions for a new mother and her 2-day old newborn. The mother asks, "How will I know if my baby is getting enough breast milk?" Which of the following responses should the nurse make?

A. "Your baby should sleep at least 6 hours between feedings."

B. "Your baby should burp after each feeding."

C. "Your baby should wet 6 to 8 diapers per day."

D. "Your baby should have a wake cycle of 30-60 minutes after each feeding."

C

26. A 39-year old multigravida client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching?

A. My fallopian tube will be tied off through a small abdominal incision

B. Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%

C. After this procedure, I must abstain from intercourse for at least 3 weeks

D. Both of my ovaries will be removed during the tubal ligation procedure

A

27. A nurse is caring for a client who is in active labor and notes late decelerations on the FHR monitor. Which of the following action should the nurse take first?

A. Apply a fetal scalp electrode

B. Increase the rate of the IV infusion

C. Administer oxygen via nonrebreather at 10 L/min

D. Change the client's position

D

28. A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

A. Administer magnesium sulfate IV

B. Provide a dark, quiet environment

C. Assess respiratory status every 4 hr

D. Evaluate neurologic status every 8 hr

E. Ensure that calcium gluconate is readily available

A,B,E

29. A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4 C (97.6 F). Which of the following is the priority nursing action?

A. Insert an indwelling urinary catheter

B. Initiate IV access

C. Witness the signature for informed consent for surgery

D. Prepare the abdominal and perineal areas

B

30. A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

A. Encourage the client to empty her bladder every 2 hr

B. Remind the client to bear down with each contraction

C. Perform vaginal examinations frequently

D. Maintain the client in the lithotomy position

A

31. A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

A. Complete abortion

B. Inevitable abortion

C. Missed abortion

D. Incomplete abortion

C

32. A nurse is providing teaching of a neonate born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

A. Preterm delivery

B. Fetal hyperinsulinemia

C. Perinatal asphyxia

D. Placental insufficiency

D

33. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A. Incompetent cervix

B. Prolapsed cord

C. Abruptio placentae

D. Placenta previa

C

34. A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?

A. Increased abdominal muscle tone

B. Posterior neck flexion

C. Decreased mobility of pelvic joints

D. Gradual lordosis

D

35. A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions

B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors

C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes

D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache

D

36. A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

A. A pink rash appears on the newborn's trunk.

B. The newborn's eyes are covered with a mask.

C. The mother applies lotion to the newborn's skin.

D. The newborn's stools increase in number.

C

37. A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a correct response by the nurse?

A I will call your primary care provider to report your concerns

B. I will take your baby to the nursery for further examination

C. This occurs because newborns lack muscle control to regulate eye movement

D. This is a concern, but strabismus is easily treated with patches

C

38. A nurse is assessing a client who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A. Vomiting

B. Tachycardia

C. Respiratory depression

D. Hypotension

D

39. A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

A. Apply fundal pressure

B. Observe for the presence of nuchal cord

C. Observe for crowning

D. Prepare to administer oxytocin

C

40. A nurse in a prenatal clinic is instructing about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

A. After the test, you will be given RhO immune globulin since you are Rh positive

B. This test requires the presence of amniotic fluid

C. This test will determine if your baby's lungs are mature

D. The test will be performed if your baby's heart beat is heard

B

41. A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

A. Monitor the client's temperature

B. Assess the fetal heart rate

C. Assess the odor of the amniotic fluid

D. Provide clean, dry underpads

B

42. A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus (PDA). Which of the following findings should the nurse expect?

A. Cyanosis with crying

B. Weak pulses

C. Systolic murmur

D. Chronic hypoxemia

C

43. A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

A. Elevate the client's legs

B. Position the client on her side

C. Administer oxygen via face mask

D. Increase the infusion rate of the IV fluid

B

44. A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A. A client who is at 38 weeks of gestation and reports a cough and fever

B. A client who missed a period and reports vaginal spotting

C. A client who is at 14 weeks of gestation and reports nausea and vomiting

D. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding

D

45. A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

A. You may carry your grandchild to the room.

B. You can push the baby to the room in a wheeled bassinet.

C. Have the mother call and I will take the baby to the room.

D. If you show me your photo identification, you can take the infant.

C

46. A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

A. Respiratory distress

B. Hypothermia

C. Accidental lacerations

D. Acrocyanosis

A

47. A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document the finding?

A. Caput succedaneum

B. Cephalohematoma

C. Molding

D. Pilonidal dimple

B

48. A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

A. Swelling in both breasts

B. Cracked and bleeding nipples

C. Red and painful area in one breast

D. A white patch on a nipple

C

49. A nurse is caring for a newborn that is large for gestational age (LGA). What is an expected finding of a macrosomic infant?

A. Decreased subcutaneous fat

B. Dry, loose skin

C. Sluggishness, hypotonic muscles

D. Bronze skin discoloration

C

50. A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A. Severe nausea and vomiting

B. Large amount of vaginal bleeding

C. Unilateral, cramp-like abdominal pain

D. Uterine enlargement greater than expected for gestational age.

C