Maternal ATI Exam 2 Proctored PDF

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1. Nurse is performing a newborn assessment, which of the following should the nurse identify as a sign of spina bifida occulta? Tuft of hair. 2. A nurse is assessing a client that is 12-hour post-partum, the client’s fundus is 2 fingerbreadths above the umbilicus, deviated to the right of midline, and less firm than previously noted. Which action should the nurse take? Assist the client to the restroom to void. 3. A nurse is teaching a client who is 36 weeks gestation and has a prescription for a non-stress test. Which of the following statements should the nurse include in her teaching? You will be offered orange juice and a snack during your test. 4. A nurse is admitting a client to the labor and delivery unit, when the client states, “My water just broke.” What is the nurses first action of priority? Monitor fetal heart rate. 5. Nurse is developing an educational program for adolescents about nutrition during the third trimester of pregnancy. Which of the following statements should the nurse include in the program? Consume three to four servings of dairy each day. 6. Nurse is assessing a client that is 38 weeks gestation during a weekly prenatal visit, which of the following findings should the nurse report to the doctor? Weight gain of 2.2 kg (4.8 pounds) 7. The nurse is providing discharge teaching to the parents of a newborn about using a car seat properly. Which of the following instructions should the nurse include? Position the car seat rear facing, in the back seat of the vehicle. 8. A nurse is preparing to collect a blood specimen from a newborn via heel stick, which of the following techniques should the nurse use to help minimize the pain? Place the newborn skin to skin on the mother’s chest.

9. A nurse is developing a plan for a client who has preeclampsia, and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the FHR continuously.

10. Nurse is caring for a client in labor who is experiencing increased rectal pressure, She is experiencing contraction that are 2-3 minutes apart, each lasting 80-90 seconds, and a vaginal examination reveals that her cervix is dilated to 9cm, the nurse should identify that the client is in which phase of labor? Transition 11. A nurse is performing a vaginal exam on a client that reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in posterior position, the nurse should identify that which of the following is the best non-pharmacological to perform to relieve the client’s discomfort? Counter-Pressure

12. A nurse is caring for a client who is at 24 weeks gestation and reports daily, mild headaches. Which of the following should the nurse include in the instructions for the plan of care? Recommend that the client perform conscious relaxation techniques daily. 13. A nurse is teaching a new mom how to bulb syringe to suction her newborn’s secretions, Which of the following instructions should the nurse include in her teaching? Stop suctioning when the newborn’s cry sounds clear. (always suction mouth before nose, nose only if you must) 14. A nurse is assessing a newborn who is 12 hours old, which of the following clinical manifestations requires intervention by the nurse? Substernal chest retractions while sleeping 15. A nurse is teaching a client about effective breast feeding who is 3 days postpartum, which of the following information should the nurse include? Newborn should appear content after each feeding.

16. Nurse is caring for a client that had uterine hypotonicity and is experiencing post-partum hemorrhage, which of the following actions is the nurse’s priority? Massage the client’s fundus. 17. Nurse is teaching a client who is 24 weeks gestation regarding a 1-hour glucose tolerance test, which of the following statements should the nurse include in her teaching? Blood glucose between 130 and 140 is considered a positive screening result. 18. Nurse is teaching a client who has pre-gestational type 1 diabetes about management during pregnancy, which of the following statements made by the client, indicates an understanding of the teaching? I will continue taking my insulin if I experience nausea and vomiting.

19. Nurse is assessing late preterm newborn, which of the following manifestation is an indication of hypoglycemia? Respiratory distress 20. Nurse is teaching a group about newborn safety, which of the following statements by a pair is indicated an understanding of the statement? I will dress my baby in flame retardant clothing.

21. Nurse is assessing a client who is in active labor and notes early deceleration in the FHR on the monitor, the client is at 39 weeks gestation, and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take? Continue monitoring the client. 22. Nurse is assessing fetal heart tones on a client who is pregnant. The nurse has noted that the fetal position is left occipital anterior. To which of the following areas of the abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart rate? Left lower quadrant. 23. Nurse is assessing a client that received Carboprost for post-partum hemorrhage, which of the following is an adverse effect of this medication? Hypertension.

24. Nurse is assessing a client who is postpartum and has ITP (isiopathic thrombocytopenia purpura). Which of the following findings should the nurse expect? Decreased platelet count. 25. Nurse is performing a vaginal exam for a client who is in active labor and reports back pain, nurse determines that the client is 8cm dilated, 100% effaced, and -2 station, the fetus is in the occiput posterior position, Which of the following actions should the nurse take? Assist the client to the hands and knees position.

26. Nurse is caring for a client that is at 22 weeks gestation, she reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? Explain to the client that this is a normal occurrence. 27. A nurse in a family planning clinic for a client who request oral contraceptives, which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? Cholecystitis, hypertension, migraine headaches

28. Nurse is caring for a client who is at 40 weeks gestation and is in early labor. The client has a platelet count of 75,000/mm^3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate? Attention-focusing 29. Nurse is caring for a client that has recently experience perinatal death, which of the following statements should the nurse make to the client? I am sad for you.

30. Nurse is assessing a full-term newborn 15 minutes after birth, which of the following findings requires intervention by the nurse? Respiratory rate of 18/min (normal respiratory rate is 30-60) 31. Nurse is assessing four newborns, which of the following should the nurse report to the provider? Newborn that is 18 hours old with a temperature of 37.7 (normal is 36.5-37.5)

32. Nurse is providing discharge teaching to a client that had cesarean birth 3 days ago, which of the following instructions should the nurse include? You can still become pregnant if you are breastfeeding. 33. Nurse is providing discharge teaching to parents whose newborn has just had a circumcision, which of the following instructions should the nurse include? Apply slight pressure with a sterile gauze pad for mild bleeding.

34. Nurse is providing discharge teaching to a client who is postpartum, for which clinical manifestation should the nurse tell the client to monitor and report to the provider? Unilateral breast pain. 35. Nurse is caring for a newborn that was transferred 30 minutes after delivery. Which of the following actions should the nurse take first? Verify the newborns identification. 36. Nurse is preparing to administer magnesium sulfate at 2g/hr IV, available 20g in 50mL of D5W, how many mL per hour? 50 37. The nurse is speaking with a client who is trying to make a decision about uterine tube occlusion. The client asks, “what effects will this procedure have on my sex life?” What is the nurse’s best response? This process should have no effect on your sexual performance or adequacy.

38. Nurse is caring for a client who is at 15 weeks of gestation, and is Rh negative, and has just had an amniocentesis, which of the following interventions is the nurse’s priority following the procedure? Monitor the fetal heart rate. 39. Charge nurse on the unit is observing a newly licensed nurse who is preparing to administer pain medication to her client, the charge nurse knows to intervene when which of the following secondary identifiers is used to identify the client? The client’s room number 40. Nurse is assessing a client who is at 26 weeks gestation, which of the following clinical manifestations should the nurse report to the provider? Decreased urine output.

41. Nurse in a woman healthcare clinic is providing teaching about nutritional intake to a client who is 8 weeks gestation. The nurse should instruct the client to increase her daily intake of which of the following supplements? Iron

42. Nurse is reviewing medical record at 1800 for a client who is 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following? Administer terbutaline.

43. A school nurse is providing teaching to an adolescent about Levonorgestrel contraception. Which of the following information should the nurse include in the teaching? You should take the medication within 72 hours following unprotected sex. 44. Nurse is providing dietary teaching to patient with hyperemesis, which of the following statements made by the client indicates an understanding of the teaching? I will at foods that appeal to my taste instead of trying to balance my diet. 45. Nurse is performing a physical assessment of a newborn upon admission to the nursery, which of the following clinical manifestations should the nurse expect? Creases, molding, lanugo 46. Nurse is discussing the differences between true and false labor with a group of expectant parents. Which of the following characteristics should the nurse include when discussing true labor? Contractions become stronger with walking. 47. Nurse in a provider’s office is reviewing the medical record of client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Pre-gestational diabetes mellitus

48. Nurse is panning care for a client who is 2 hours post-partum, which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Demonstrate to the client how to perform a newborn bath. 49. Nurse is providing teaching to a client that about the physiological changes that occur during pregnancy. The client is at 10 weeks gestation and has a BMI within expected range, which of the following statements indicates a client’s understanding about the teaching? I will likely need to use alternative positions for sexual intercourse.

50. A nurse is teaching clients about taking folic acid in a prenatal class, the nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities? Neural Tube Defect 51. Nurse is preparing to perform Leopold’s maneuver for a client. Identify the sequence that the nurse should follow: Palpate the fundus, determine the location, palpate for fetal part, identify the attitude of the head. 52. Nurse is providing prenatal teaching to a client that is 26 weeks gestation, which of the following positions should the nurse recommend for the client to increase circulation to the placenta? Side Lying 53. Nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord, which of the following clinical manifestations should the nurse expect to see? Petechiae

54. Nurse is providing teaching about non-pharmacological pain management to a breastfeeding client that has engorgement. The nurse should recommend what for application? Cold cabbage leaves 55. Nurse is assessing a client who is one day postpartum with a vaginal hematoma, which of the following manifestations should the nurse expect to find? Vaginal pressure 56. Nurse is providing teaching to a client that gave birth 2 hours ago regarding facility policy for newborn safety. Which of the following client statements indicated that the client understood the teaching? The person who comes to take my babies pictures will have a photo identification badge.

57. Nurse is planning care for a client who is in labor and requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in her plan o care? Monitor the client’s blood pressure every 5 minutes following the first dose of anesthesia. 58. Nurse is caring for a newborn who is undergoing phototherapy for hyperbilirubinemia, which of the following actions should the nurse take Cover the newborn’s eyes while under the phototherapy light. 59. Nurse is caring for a client who is to receive oxytocin to augment her labor, which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to provider? Late decelerations 60. Nurse is providing education about family bonding to parents who recently adopted a newborn, the nurse should make which of the following suggestions to aid the families 7year-old child in accepting the new family member? Obtain a gift from the newborn to present to the child....