ATI Final Exam

A nurse is performing a funday assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document?

moderate lochia rubra

during ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. on assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. which of the following findings should the nurse interpret this date as being?

a normal postural discharge of lochia

a nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. which of the following should the nurse include?

use perineal squeeze bottle to cleanse the perineum, apply a topical anesthetic cream or spray to the perineum, apply cold or ice packs to the perineum

a nurse is assessing a postpartum client for fundal heigh, location, and consistency. the fundus is noted to be displaced laterally to the right side, and there is uterine atony. the nurse should identify which of the following conditions as the cause of uterine atony?

urinay retention

a nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the vaccine. which of the following statements made by the client indicates understanding?

“i need a second vaccination at my postpartum visit”

a nurse is caring for a client who is 1 day postpartum. the nurse is assessing for maternal adaptation and parent-newborn bonding. which of the following behaviors by the client indicates a need for the nurse to intervene?

demonstrates apathy when the newborn cries, views the newborn’s behavior as uncooperative during diaper change

a nurse concludes that the parent of a newborn is not showing positive indications of parent-newborn bonding. the parent appears anxious and nervous when the nurse brings the newborn to the room. which of the following actions should the nurse use to promote parent-newborn bonding?

provide education about infant care when the parent is present

a nurse in the delivery room is planning care to promote parent-newborn bonding for a client who just delivered. which of the following is the priority action by the nurse?

position the newborn skin-to-skin on the client’s chest

a nurse is caring for a client 2 days postpartum. the client states, “my 4-year-old son was toilet trained and now he is frequently wetting himself”. which of the following statements should the nurse provide to the client?

“your son is displaying a common negative response to the birth of a sibling”

a nurse is conducting a home visit for a client who is 1 week postpartum and breast feeding. the client reports breast engorgement. which of the following recommendations should the nurse make?

apply cold compresses between feedings

a nurse is providing discharge instructions toa postpartum client following a vaginal birth with a fourth-degree laceration. the client reports leaking every time they sneeze or cough. what interventions should the nurse suggest

Pelvic floor exercises like kegel

a nurse is providing discharge instructions for a client. at 4 weeks postpartum, the client should contact the provider for which of the following client findings?

sore nipple with cracks and fissures(mastitis)

a nurse is providing to four clients on the postpartum unit. which of the following clients is at the greatest risk for developing a postpartum infection?

a client who does not was their hands between perineal care and breastfeeding

a nurse is planning care for a client who is postpartum and has thrombophlebitis. which of the following nursing interventions should the nurse include in the plan of care?

measure leg circumference

a nurse is caring for a client who has disseminated intravascular coagulation (DIC). which of the following antepartum complications should the nurse understand is a risk factor for this condition?

preclampsia

a nurse on a postpartum unit is assessing a client who is being admitted with a suspected deep vein thrombosis (DVT). which of the following clinical findings should the nurse expect?

calf tenderness on palpation, an area of warmth over the thrombus, and an elevated temperature.

a nurse is caring for a client who is postpartum. the nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage?

Increased heart rate and decreased blood pressure.

a nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. which of the following factors should the nurse include in the teaching?

prolonged labor, inversion of the uterus, and retained placental fragments

a nurse is reviewing discharge teaching with a client who has a urinary tract infection. which of the following statements by the client indicates understanding the teaching?

I will drink large amounts of fluids to flush the bacteria from my urinary tract and i will take Tylenol for any discomfort.

a nurse on the postpartum unit is caring for four clients. which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection?

a client who had premature rupture of membranes and prolonged labor.

a nurse is caring for a client who has mastitis. what is the typical causative agent of mastitis?

staphylococcus aureus, escherichiacoli, and streptococcus species.

a nurse is discussing manifestations of postpartum blues with a newly licensed nurse. which conditions are associated with these manifestations?

mood swings, anxiety, feelings of sadness, crying, insomnia, and lack of appetite.

a nurse is caring for a postpartum client who delivered there third infant 2 days ago. which if the following manifestations could indicate postpartum depression?

fatigue, insomnia, and flat affect

a nurse is assessing a client who has postpartum depression. the nurse should expect which of the following manifestations?

thoughts of self-harm, anxiety about assuming a new role as a parent, feeling of inadequacy with the new role as a parent.

a nurse is caring for a client who has postpartum psychosis. which of the following actions is the nurse’s priority?

ask the client is they have thoughts of harming themselves or their infant.

a nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age of the newborn, the nurse should classify this neonate as which of the following?

appropriate for gestational age (AGA)

a nurse is completing an assessment. which of the following data indicate the newborn is adapting to extrauterine life?

apnea for 10-second periods and obligatory nose breathing.

a nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn’s lower back. the nurse should include which of the following information in the teaching?

this is more commonly seen in newborns who have dark skin and is known as a Mongolian spot.

a nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the mouth. this finding is a characteristic of which of the following conditions?

Epstein’s pearls

a nurse is assessing the reflexes of the newborn. in checking for the Moro reflex, the nurse should perform which of the following?

hold the newborn is a semi-sitting position, then allow the newborn’s head and trunk to fall backward

a nurse is taking a newborn to a parent following a circumcision. which of the following actions should the nurse take for security purposes?

match the parent’s identification band with the newborn’s band.

a nurse is caring for a newborn immediately following birth. which of the following nursing interventions is the highest priority?

covering the newborn’s head with a cap

a newborn was not dried completely after birth. this places the infant at risk for which of the following type of heat loss?

evaporation

a nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. which if the following medications should the nurse anticipate administering?

erythromycin

a nurse is preparing to administer a vitamin K injection to a newborn. What explanation should the nurse give for why this medication is given?

it assists with blood clotting.

a nurse is reviewing breastfeeding positions with the parent of a newborn. which of the following positions should the nurse discuss?

cradle

a nurse is giving instructions to a parent about how to breastfeed their newborn. which of the following actions by the parent indicates understanding of the teaching?

when latched on, the infant’s nose, cheek, and chin are touching the breast.

a nurse is teaching a group of new parents about proper techniques for bottle feeding. which of the following instructions should the nurse provide?

keep the nipple full of formula throughout the feeding.

a nurse is reviewing formula preparation with parents who plan to bottle feed their newborn. Which if the following instructions should the nurse provide?

place used bottles in the dishwasher, check the nipple for appropriate flow of formula, and use tap water to dilute concentrated formula.

a nurse is caring for a newborn. which of the following actions by the newborn indicates readiness to feed?

attempts to place their hand in their mouth.

a nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. which of the following statements made by the parent indicates an understanding of the teaching?

i will clean the penis with each diaper change.

a nurse is reviewing care of the umbilical cord with the parent of the newborn. which of the following instructions should the nurse include in the teaching?

keep the diaper folded below the cord.

a nurse is reviewing car seat safety with the parents of a newborn. which of the following instructions should the nurse include in the teaching regarding car seat position?

back seat, rear facing.

a nurse is conducting an in-service for a newly licensed nurse about neonatal opioid withdrawal syndrome (NOWS) in newborns. which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

the newborn will have a continuous high-pitched cry.

a nurse is caring for a newborn who was born at 32 weeks of gestation. the newborn’s birth weight is 1,100 g. which of the following are expected findings in this newborn?

lanugo, weak grasp reflex, and translucent skin.

a nurse is caring for a client who is at 42 weeks’ gestation and in labor. the client asks the nurse what to expect because the baby is postmature. which if the following statements should the nurse make?

your baby’s skin will have a leathery appearance

a nurse is caring for a newborn who has a high bilirubin level and is receiving phototherapy. which of the following findings is the priority for the nurse to report to the provider?

sunken fontanels.

A nurse is discussing the use of a penile condom with a client. Which of the following information should the nurse include in the teaching as a disadvantage of using penile condoms?

A. Reduces spontaneity of intercourse

C. One time usage

E. Decreases sensation

A nurse is performing a health assessment for a client who has been unable to conceive for 16 months. the nurse should recognize that which of the following are findings the nurse should report to the provider?

B. Abnormal uterine contractions

C. History of STIs

D. Tobacco use

A nurse is caring for a client who is pregnant and states that their last menstrual period was September 9th. What is the clients estimated date of delivery?

1 day of LMP-3 months+7 days+1 year= June 16th.

A nurse is preparing to draw laboratory test from a client who is 8 weeks of gestation and at the initial prenatal visit. Which of the following tests should the nurse anticipate obtaining.

A. CBC with differential

B. Rubella titer

C. Blood type, Rh factor

A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include?

A. Breast tenderness

B. Urinary frequency

C. Epistaxis

A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include?

A. Vaginal bleeding

A nurse in a prenatal clinic is caring for four clients. Which of the following clients’ weight gain should the nurse report to the provider?

B. 3.6 kg (8 lb) weight gain in the first trimester

A nurse is discussing with a client who is 6 weeks gestation food sources high in dietary content for folate and iron.

Iron (A. Beef liver, D. Poultry).

Folate (B. leafy vegetables, C. Orange juice)

A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid supplements"?

D. Neural tube defects

A client in a prenatal clinic is providing education to a client who is at 8 weeks of gestation. The client states, “I don’t like milk. Which of the following foods should the nurse recommends as a good source of calcium?

A. Dark green leafy vegetables

A nurse is reviewing findings of a client’s biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test?

B. Fetal breathing movement

C. Fetal tone

E. Amniotic fluid volume

A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make?

D. “It awakens a sleeping fetus”.

A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). which of the following findings are indications for this procedure?

A. Decreased fetal movement

B. Intrauterine growth restriction (IUGR)

C. Post maturity

A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?

“You should empty your bladder prior to the procedure”.

A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity?

B. Lecithin-to-sphingomyelin ratio (L/S ratio)

A nurse in the ED is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, “I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device”. The nurse should suspect which of the following?

B. Ectopic pregnancy

A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition?

D. report of severe shoulder pain

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea; vomiting; and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal heigh larger than expected. Which of the following complications should the nurse suspect?

C. Hydatidiform mole

A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect, the provider will prescribe?

A. Betamethasone

A nurse is proving care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing this condition?

B. Blunt abdominal trauma

C. Cocaine use.

E. Cigarette smoking

A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client?

A. Vacuum extractor

C. Forceps

E. Internal fetal monitoring

A nurse is caring for a client who is at 32 weeks of gestation and tested positive for gonorrhea and chlamydia. which of the following medications should the nurse anticipate that the provider will prescribe?

A. Azithromycin

E. Ceftriaxone

A nurse is caring for a client who is pregnant and has condyloma acuminata. Which of the following therapeutic procedures should the nurse anticipate the provider performing?

B. Cryosurgery

A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect?

A. Joint pain

B. Malaise

C. Rash

E. Tender lymph nodes

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client?

A. Diabetes

B. Multifetal pregnancy

D. Gestational trophoblastic disease

A nurse is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering in magnesium sulfate toxicity is suspected?

Calcium gluconate

A nurse is assisting with the care of a client who has severe preeclampsia who is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as magnesium sulfate toxicity?

A. Respirations less than 12/min

B. Urinary output less than 25 ml/hr

D. Decreasing level of consciousness

A nurse is assisting with the care of a client who reports manifestations of preterm labor. Which of the following findings are risk factors for this condition?

A. Urinary tract infection

B. Multifetal pregnancy

D. Substance use

E. uterine abnormalities

A nurse is assisting with the care for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication?

A. Fetal distress

B. Vaginal bleeding

A nurse is assisting with providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate, the provider will prescribe to hasten fetal lung maturity?

Betamethasone

A nurse is caring for a client who is at 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first?

B. check the FHR

A nurse is completing an admission assessment for a client who is at 39 weeks of gestation and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing?

B. infection

A client calls a provider’s office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. which of the following manifestations is the client experiencing?

D. True contractions

What is true labor?

True labor is characterized by regular, painful contractions that progressively become stronger and more frequent, leading to cervical dilation and effacement. Unlike false labor, these contractions do not subside with rest or hydration.

What is false labor?

False labor refers to irregular, often painless contractions that do not lead to cervical changes and typically subside with rest or hydration. These contractions can be mistaken for true labor but do not indicate the onset of delivery.

A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. which of the following actions should the nurse take?

D. Place an oxygen mask over the client’s mouth and nose.

A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client?

B. sacral counterpressure

A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3-5 minutes and becoming stronger. A vaginal exam reveals that the client’s cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which if the following actions should the nurse take?

A. encourage use of patterned breathing techniques

C. Administer opioid analgesic medication

D. Suggest application of cold

A nurse is caring for a client who is in the second stage of labor. The client’s labor has been progressing, and a vaginal birth is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered?

A. Pudendal

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client’s partner asks about the purpose of IV fluids. Which of the following statements should the nurse make?

C. “it is needed to counteract hypotension”.

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?

B. palpate the fundus of the uterus.

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing?

D. Relaxation between uterine contractions

A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150-155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following?

A. Moderate variability

B. FHR accelerations

D. Normal baseline FHR

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take?

A. assist the client into the left-lateral position (to improve uteroplacental perfusion).

A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include?

B. It can detect abnormal fetal heart tones early

D. It allows for accurate readings with maternal movement

E. It can measure uterine contraction intensity

A nurse is planning care for a newly admitted client who reports, “I am in labor, and I have been having vaginal bleeding for 2 weeks”. Which of the following should the nurse include in the plan of care?

D. Defer vaginal examinations.

A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make?

D. A distended bladder reduces pelvic space needed for birth

A nurse is caring for a client and partner during the second stage of labor. The client’s partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make?

C. The vaginal area will bulge as the baby’s head appears

A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation?

A. Lengthening of the umbilical cord

D. Appearance of dark blood from the vagina

E. Fundus firm upon palpation

A nurse is caring for a client who had no prenatal care. is Rh negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version?

C. Rho(D) immune globulin to prevent Rh sensitization.

A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin?

B. Duration of 90-120 seconds

A nurse is caring for a client who has been in labor for 12 hr with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy?

A. fetal engagement

A nurse is caring for a client who is at 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion?

A. Oligohydramnios

C. fetal cord compression