ATI Maternal Retake - Ati Proctored. Level 3. PDF

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Maternal Retake #2: Level 2-Corrected Which of the following assessment findings in an infant should indicate to a nurse that suctioning of the nasopharynx is needed? A) The infant is beginning to cough B) The newborns pulse oximetry is 91 C) The infant's respiratory rate is 32/min. D) The infant's ...

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Maternal Retake #2: Level 2-Corrected 1) Which of the following assessment findings in an infant should indicate to a nurse that suctioning of the nasopharynx is needed? A) The infant is beginning to cough B) The newborns pulse oximetry is 91 C) The infant's respiratory rate is 32/min. D) The infant's respiratory rate is irregular 2) A nurse is providing teaching to a postpartum client who has type 1 diabetes and is breastfeeding her newborn. Which of the following instructions should the nurse give to the client? A) Take more insulin with each meal that you did prior to pre pregnancy B) Maintain scheduled mealtimes for yourself C) Check your blood glucose levels every 8 hours D) Limit your carbohydrate intake to 30 grams per day 3) A nurse is assessing the reflexes of a term newborn. After placing the newborn in a supine position, which of the following would the nurse use to elicit the Moro reflex A) Turn the newborn’s head to one side B) Make a loud noise above the newborn C) Tap the newborns forehead with a finger D) Touch the newborns cheek with a finger 4) A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A) Give the newborn 1 oz of glucose water every 4 hours B) Apply a thin layer of lotion to the newborns skin every 8 hours C) Dress the newborn in a thin layer of clothing during the therapy D) Ensure the newborns eyes are closed beneath the shield 5) A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse asses first? A) A client who has hyperemesis gravidarum and a sodium level of 110 B) A client who has preeclampsia and a creatine level of 1.1 C) A client who has diabetes mellitus and an HbA1c of 5.8 D) A client who has placenta previa a hematocrit of 36 6) A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes. The test reveals no accelerations of the fetal heart rate for 20 minutes. Which of the following actions should the nurse take? A) Perform vibroacoustic stimulation B) Collect a specimen for an indirect Coomb’s test C) Conduct a vaginal exam D) Place the client in the Trendelenburg position 7) A nurse is preparing to administer gentamycin 2 mg/kg Im to a client who has pelvic inflammatory disease and weighs 132 lb. Available is gentamycin injection 40 mg/ml. How many ml should the nurse administer? 3 mL 8) A nurse is caring for a client who is 1-day post-partum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take? A) Have the client limit the length of breastfeeding to 5 minutes per breast B) Assess the newborns latch while breastfeeding C) Offer supplemental formula between the newborn’s feedings D) Instruct the client to wait 4 hours between daytime feedings 9) A nurse is admitting a client who is in active labor and has had two prior cesarean births. The nurse should identify that the client is at an increased risk for which of the following complications? A) Uterine rupture B) Precipitous labor C) Failure to progress D) Abruptio placentae

10) A nurse is caring for a 2-day old newborn who was born at 35 weeks gestation. Which of the following actions should the nurse take? A) Measure the abdominal circumference at the level of the newborn’s umbilicus every 12 hours B) Provide the newborn with an iron rich formula containing vitamin b12 every 12 hours C) Administer nitric oxide inhalation therapy to the newborn D) Insert an orogastric decompression tube with low suction 11) A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concerns about preparing her 2-year-old for a new sibling. A) Move your toddler to his new bed 2 months before the baby comes home B) Avoid bringing your toddler to prenatal visits C) Require scheduled interactions between the toddler and the baby D) Let your toddler see you carry the baby into the home for the first time 12) A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? A) Place newborn bassinets at least 3 feet apart B) Maintain airborne precautions C) Allow parents to enter the nursery if wearing a mask D) Place the newborns foot on a sterile field during a heel stick 13) A nurse is caring for a client who is in active labor and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client’s blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse expect? A) Placenta Previa B) Amniotic fluid embolism C) Uterine rupture D) Umbilical cord prolapse 14) A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes. Which of the following medications should the nurse expect to administer? A) Nifedipine B) Chlorpromazine C) Glyburide D) Levothyroxine 15) 1) assess the newborn for reflex bradycardia 2) compress the bulb syringe 3) place bulb in mouth 4) use the bulb syringe to suction nose 16) A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? A) Urine protein of 3+ B) Deep tendon reflexes of 2+ C) Hemoglobin 13 D) Blood glucose 110 17) A nurse is admitting a client who is at 38 weeks gestation following spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take first? A) Request that the provider insert an intrauterine pressure catheter B) Initiate oxytocin via continuous IV infusion C) Place the client in a left lateral position D) Exert continuous upward pressure on the presenting parts 18) A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client? A) An urge to have a bowel movement during contractions B) Progressive sacral discomfort during contractions C) A sense of excitement and warm, flushed skin D) Intense contractions lasting 45 to 60 seconds

19) A charge curse is teaching a newly licensed nurse about Rh immune globulin administration. Which of the following should the charge nurse include as an indication for the administration of Rh immune globulin? A) Hyperemesis gravidarum B) Rh-positive blood test results C) Prescription for amniocentesis D) Anemia 20) A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate? A) LLQ B) LUQ C) RLQ D) RUQ 21) A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? A) Temperature 36.5 degrees C (97.7 degrees F) B) Blood pressure 80/50 mm Hg C) Respiratory rate 55/min D) Heart rate 72/min 22) A nurse is performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following? A) Decreased maternal hormones during pregnancy B) Congenital anomaly C) Preterm gestational age D) Ambiguous secondary sex characteristics 23) A nurse is reviewing the medical records of a client who had a vaginal delivery 3 hours ago. Which of the following findings place the client at risk for post-partum hemorrhage? SATA A) History of uterine atony B) Vacuum assisted birth C) Labor induction with oxytocin D) Normal weight E) History of HPV 24) A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take? A) Position the client in a knee-chest position B) Give terbutaline subcutaneously C) Apply oxygen via nonrebreather face mask D) Administer a bolus infusion of lactated Ringer’s 25) A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks gestation. Which of the following findings requires an intervention by the nurse? A) Uterine contractions lasting 20 to 30 seconds each B) An FHR that peaks 20 beats above baseline C) Three uterine contractions within a 20-minute period D) One acceleration of the FHR within a 20-minute period 26) A nurse is caring for a client who had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse effect? A) Fetal bradycardia B) Maternal hypertension C) Decreased ability to bear down D) Uterine hyperstimulation

27) A nurse is assessing a client who is requesting a combined oral contraceptive. Which of the following findings should indicate to the nurse that the client has a contraindication? A) The client is breastfeeding her 4-week-old newborn B) The client is 25 years old C) The client weighs 115 kg D) The client drinks 240 ml of wine a day 28) A nurse is admitting a client to the birthing unit who reports contractions started 1 hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? A) Postpartum hemorrhage B) Incompetent cervix C) Ectopic pregnancy D) Hyperemesis gravidarum 29) A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A) Increased muscle tone B) Jitteriness C) Petechiae D) Abdominal distension 30) Image of prolonged decelerations

31) A nurse is caring for a client who has bladder distension following a vaginal birth. Which of the following actions should the nurse take first? A) Insert a urinary catheter B) Pour warm water over the client’s perineum C) Assist the client to the bathroom D) Offer the client a sitz bath 32) A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion? A) Elevated hCG B) Scant, bright red spotting C) Cervical dilation D) Slight abdominal cramps 33) A nurse manager on the labor and deliver unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Information included in teaching? A) Mothers will receive prophylactic treatment with acyclovir prior to delivery B) Lesions are visible on the mother genitalia C) Transmission can occur via the saliva and urine of the newborn D) The infection requires that airborne precautions be initiated 34) A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Highest in fiber content? A) Cabbage B) Oatmeal C) Asparagus D) Lentils

35) A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? A) Expect two to four wet diapers every 24 hours B) Offer the newborn 30 ml of water between feedings C) Feed the newborn 5 to 10 minutes per breast D) Allow the baby to feed at east every 3 hours 36) A nurse is assessing a full-term newborn upon admission to the nursery Which of the following clinical findings should the nurse report to the provider. A) Subconjunctival hemorrhage B) Rust stained urine C) Single palmar creases D) Transient circumoral cyanosis 37) A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following clinical findings should the nurse expect? A) Temperature 37.4/99.3 B) Uterine tenderness C) Scant lochia D) WBC 9,000 38) A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus. Which of the following is an appropriate action for the nurse to take following the birth of the newborn? A) Initiate contact precautions for the newborn B) Administer IV antibiotics for the newborn C) Encourage the mother to breastfeed the newborn D) Cleanse the newborn immediately after delivery 39) A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client? A) Notify your baby’s pediatrician if he urinates less than six times a day B) Swaddle your baby tightly with his legs extended before laying him down to sleep C) Place triple antibiotic ointment on your baby’s umbilical cord twice per day D) Retract the foreskin to clean your baby’s penis during each bath 40) A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for group B strep. Which of the following medications should the nurse plan to administer to the client? A) Ampicillin B) Cefotetan C) Doxycycline D) Fluconazole 41) A nurse on an antepartum unit is receiving change of shift report for four clients. Which of the following should the nurse assess first? A) A client who is at 38 weeks gestation and is experiencing painful urination B) A client who is at 12 weeks gestation and is experiencing nausea and vomiting C) A client who is at 34 weeks gestation and is experiencing epigastric pain and headache D) A client who is at 39 weeks gestation and is experiencing cramping and spotting 42) A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A) Dress the newborn in lightweight clothing B) Measure the newborns temperature every 8 hours C) Avoid using lotion or ointment on the newborns skin D) Keep the newborn supine throughout the treatment

43) A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes. Which of the following findings should the nurse report to the provider? A) BUN 25 B) HbA1c 6% C) Hct 34% D) Platelets 170,000 44) A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication? A) Moderate fetal heart rate variability B) Blood pressure 136/88 C) Urinary output 120 mL in 2 hours D) Respiratory rate 10/min 45) A nurse is teaching a newly licensed nurse about the use of ultrasonography in the first trimester. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) Ultrasound is used to determine gestational age in the first trimester B) Ultrasound is used to perform biophysical profile in the first trimester C) Ultrasound is used to observe for placental maturity in the first trimester D) Ultrasound is used to detect IUGR in the first trimester 46) A nurse is assessing a newborn whose mother had a primary cytomegalovirus infection during pregnancy. The newborns acquired CMV trans placentally. Which of the following findings should the nurse expect the newborn to exhibit? A) Urinary tract infection B) Cataracts C) Hearing loss D) Macrosomia 47) Estimated delivery date of LMP August 10th A) May 20 B) May 13 C) May 17 D) May 3 48) A nurse is providing teaching to a client about the purpose of her upcoming indirect Coomb’s test. Which of the following statements should the nurse include in the teaching? A) The test determines if your baby is at risk for developing hypoglycemia B) This test studies blood flow in the fetus and placenta using ultrasound waves C) This test will detect the presence of RH positive antibodies in your blood D) This test will determine the amount of amniotic fluid around the fetus 49) A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision cite. Which of the following is an appropriate response by the nurse? A) Apply povidone iodine 2x daily to site B) I will need to obtain a sample for testing C) Wipe the discharge away gently with a washcloth and warm water for the next 48 hours D) Discharge is common during the first 24-72 hours following a circumcision 50) A nurse is caring for a client who is 12 hours postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take? A) Apply a moist, warm compress to the perinium B) Provide the client with a cool sitz bath C) Apply povidone-iodine to the client’s perineum site D) Administer methylergonovine 0.2 mg IM 51) A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A) I can have a mid-day snack with soft cheese B) I can purchase a seafood salad from the grocery store C) I can eat grilled chicken on a bun at lunch time

D) I can still have a hot dog at the ballpark 52) A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion? A) Place the client in a Trendelenburg position B) Assist the client to void C) Administer oxygen to the client via face mask D) Give calcium gluconate to the client 53) A nurse is caring for newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/minute, and an axillary temperature of 36.1 (97). Which of the following actions should the nurse take? A) Apply a cap to the newborns head B) Obtain an oxygen saturation level C) Reposition the newborn D) Give the newborn a warm bath 54) A nurse is caring for a client who is at 30 weeks of gestations and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? A) Hyperglycemia B) Urine output 20 mL/hour C) Hypertension D) Respiratory rate 16/min 55) A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect? A) Sharp pelvic pain B) Bright red vaginal discharge C) Elevated blood pressure D) Scaphoid abdomen 56) A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations. Which of the following actions should the nurse take? A) Place the client in a lateral position B) Decrease maintenance IV solution infusion rate C) Administer misoprostol 25 mcg vaginally D) Administer oxygen via face mask 57) A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? A) Monitor the rectal temperature every 4 hours B) Cleanse the site with povidone-iodine C) Administer broad spectrum antibiotics D) Prepare for surgical closure after 72 hours 58) A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include? A) Breasts will be firm and tender 3 to 5 days after delivery B) Bleeding will remain bright red for the next 6 to 8 weeks C) You don’t need to use birth control if you are exclusively breastfeeding D) You should begin performing Kegel exercises 6 to 7 weeks after delivery 59) A nurse is caring for a client who has pregestational diabetes. Which of the following findings should indicate to the nurse the client has hyperglycemia? A) Dizziness B) Increased urination C) Sweating D) Double vision

60) A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements indicate an understanding of the teaching? A) The nurse should wait for the first Apgar score before initiating resuscitation efforts B) The nurse should identify that the newborn is in severe distress with an Apgar score of 8 C) The nurse should measure the newborns muscle tone when assigning an Apgar score D) The nurse should determine the Apgar score at 2 and 7 minutes after birth 61) A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? A) Increased respiratory rate B) Increased fetal movement C) Increased muscle weakness D) Increased urine output 62) A nurse ...