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Atipnmaternalnewborn PDF
Atipnmaternalnewborn PDF
FORM A
1. A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting.
Which of the following findings should the nurse identify as an indication that the client has
hyperemesis gravidarum?
a. Ketonuria
i. Occurs due to the breakdown of fat secondary to malnutrition or starvation
2. A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse report to the provider?
a. Blurred vision
i. An indication that the client might have preeclampsia
3. A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling
efforts. Which of the following neonatal data collection tools should the nurse expect to
complete?
a. Neonatal abstinence scoring system
i. Exhibiting manifestations of opioid withdrawal and should be screened
ii. Additional manifestations of withdrawal include restlessness, tremors, increased
muscle tone, and an exaggerated Moro reflex
4. A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions
should the nurse take?
a. Place an opaque mask over the newborn’s eyes
i. To prevent damage to the retinas – remove mask for feedings
5. A nurse is assisting in the care of a newborn immediately following birth. Which of the following
images should the nurse identify as an indication that the newborn was a myelomeningocele?
a. First picture – exposed spinal cord and fluid filled sac, priority intervention is to maintain
the integrity of the sac
i. Myelomeningocele occurs when the neural tube fails to close, and the meninges
and spinal cord herniate
1. Defect most often occurs in the lumbar area and may be covered by a
thin membranous sac
6. A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should
the nurse report to the provider?
a. Apical heart rate of 90/min while crying
i. Is below the expected reference range of 110-160 bpm for a newborn; 80-100
bpm while sleeping; and up to 180 bpm while crying
7. A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn.
The client reports perineal pain of 6 on a scale from 0-10. The nurse also notes mild perineal
edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the
right. Which of the following action is the nurse’s priority?
a. Help the client ambulate to the toilet
i. Greatest risk is postpartum hemorrhage from uterine atony; help client to
urinate & completely empty the bladder, which will allow the uterus to contract
8. A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and has gestational
diabetes mellitus. Which of the following information should the nurse include in the teaching?
a. Consume at least 2000 cal/day
i. Is about 35 cal/kg/day – will ensure adequate glucose intake and prevent
hypoglycemia
9. A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in
newborns with a group of clients who are pregnant. Which of the following risk factors should
the nurse include?
a. Prematurity
i. A newborn who is premature has inadequate surfactant production, which can
lead to RDS
10. A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why
folic acid supplements are necessary. The nurse should inform the client that the purpose of the
folic acid supplement is to do which of the following?
a. Prevent certain kinds of birth defects
i. Help prevent neural tube defects
11. A nurse is reinforcing discharge teaching about methods to prevent engorgement during
lactation suppression with a client who is bottle-feeding her newborn. Which of the following
statements should the nurse identify as an indication that the client understands the
instructions?
a. “I will apply cold cabbage leaves to my breasts throughout the day.”
i. Frequent application of cold leaves to breasts can prevent engorgement
ii. Should also apply ice packs or cold compresses to breasts, take mild analgesics,
and wear a well-fitting and supportive bra
12. A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor.
Which of the following findings should the nurse report to the charge nurse?
a. Prolonged deceleration of FHR
i. Can be a manifestation of an emergent condition, such as uterine rupture or
umbilical cord prolapse
ii. Charge nurse should notify provider about this change
13. A client requests information about the use of a diaphragm for birth control. Which of the
following statements should the nurse make?
a. “You will need to replace your diaphragm every 2 years.”
14. A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent
episodes of nausea and vomiting. Which of the following instructions should the nurse include?
a. Consume small meals frequently each day
i. 5-6 small meals throughout the day – should avoid an empty stomach, as this
increases nausea
15. A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic
shock. Which of the following actions should the nurse take?
a. Insert an indwelling urinary catheter
i. To monitor output closely – decrease kidney perfusion caused by shock can lead
to oliguria
16. A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which
of the following recommendations should the nurse include?
a. Instruct the client to apply warm compresses to the affected breast
i. Will decrease inflammation and edema – will enable more effective emptying of
the breast to prevent milk stasis, which decreases bacterial growth
17. A nurse is reinforcing teaching about car seat safety with the parent of a newborn. Which of the
following client statements indicates an understanding of the teaching?
a. “If my baby rides in a car with no back seat, the passenger air bag must be turned off.”
i. To prevent potential injuries caused by air bag deployment
18. A nurse is planning to administer terbutaline to a client who is experiencing preterm labor.
Which of the following routes of administration should the nurse plan to use?
a. Subcutaneous
i. Relaxes the smooth muscles and inhibits uterine activity – subcutaneously every
4 hours
19. A nurse is reviewing the laboratory results of a 4-hour-old newborn. Which of the following
findings should the nurse report to the provider?
a. Platelet count 120,000/mm3
i. Is below the expected reference range of 14-24 g/dL for a newborn
20. A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for nifedipine.
Which of the following outcomes should the nurse expect from this medication?
a. Cessation of uterine contractions
i. A calcium channel blocker used to decrease uterine contractions by relaxing the
smooth muscle of the uterus
21. A nurse is reinforcing teaching about food sources that are high in folate with a group of clients
who are pregnant. Which of the following foods should the nurse recommend to this group as
the best source of folate?
a. ½ cup dried peas
i. Provides 127 mcg of folate
ii. Should consume 400 mcg of folate/day
22. A nurse is reinforcing teaching with a client who has asked about continuing routine exercise
during pregnancy. Which of the following responses should the nurse make?
a. “Drink plenty of water after exercising.”
i. Drink plenty of water during and after exercising to decrease the risk of
dehydration from diaphoresis
23. A nurse is caring for a client during the postpartum period. Which of the following findings
should the nurse expect during the first 24 hours following birth?
a. Diuresis
i. Results from the loss of excess fluid that is retained during pregnancy
b. Discharge of clear, yellow fluid from the breasts
i. Called colostrum is present for 3-5 days until the mother’s milk appears and can
leak from the breasts beginning in the third trimester of pregnancy
c. Lower abdominal cramping
i. Results from the contraction of the uterus as it decreases in size
24. A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn’s
grandfather asks if he may take the newborn to his daughter’s room. Which of the following
responses should the nurse make?
a. “Let me wash my hands and then I’ll take the baby to his mother.”
i. Only facility personnel with appropriate identification badges that indicate that
the individual works specifically in the maternal-newborn unit should transport
newborns
25. A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following
findings should the nurse identify as an indication of a potential complication of pregnancy?
a. Epigastric pain
i. A manifestation of preeclampsia
26. A nurse is assisting with collecting data from a newborn who was born 2 hours ago and has
respiratory distress. Which of the following findings should the nurse report to the provider?
a. Tachypnea
i. Respiratory rate greater than 60/min
b. Nasal flaring
c. Retractions
d. Expiratory grunting
i. All are associated with respiratory distress in the newborn
27. Nurse is reinforcing family planning options with a client who is requesting information about
contraceptives. Which of the following client statements indicates an understanding of the
teaching?
a. “I can use water-soluble lubricant when my partner wears a latex condom.”
i. Water-soluble lubricant should be used with male latex condoms, because the
use of any other lubricant can compromise the integrity of the condom
28. A nurse is assisting with the care of a client who is postpartum and is receiving magnesium
sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should
the nurse identify as manifestations of magnesium toxicity?
a. Decreased respiratory rate
b. Decreased level of consciousness (LOC)
c. Double vision
i. All manifestations of magnesium sulfate toxicity
29. A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium
sulfate via continuous IV infusion. Which of the following statements should the nurse include in
the teaching?
a. “Your fluid intake will be limited to no more than 125 milliliters per hour.”
i. To prevent fluid overload
30. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should
the nurse recommend the provider see first?
a. A client who is at 37 weeks of gestation and reports a persistent headache
i. A persistent headache is a manifestation of preeclampsia
31. A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings
should the nurse report to the provider?
a. 2+ urinary protein
i. A manifestation of preeclampsia
32. A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy.
Which of the following laboratory values should the nurse recognize as an indication that the
therapy has been effective?
a. Total bilirubin 5 mg/dL
i. Used to treat newborns who have hyperbilirubinemia – monitor the newborn’s
bilirubin level before, during, and after phototherapy – expected reference range
of 1-12 mg/dL
33. A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction.
Which of the following statements by the parent indicates an understanding of the teaching?
a. “I will ask the nurse to take my baby back to the nursery if I need to leave my room.”
i. Instruct parent not to leave the newborn unattended – if need to leave the
room, should call nurse to transport newborn back to nursery
34. A nurse is collecting data from a newborn whose mother had gestation diabetes mellitus. Which
of the following findings should the nurse report to the provider?
a. Blood glucose 28 mg/dL
i. Is below expected reference range of 40-45 mg/dL for a newborn
35. A nurse is collecting data from a client who is 32 hours postpartum. Which of the following
findings should the nurse expect?
a. Urine output of 3000 mL in 24 hours
i. Expect postpartum diuresis to begin approximately 12 hours after birth –
expected urine output of 3000 mL/24 hours is expected
36. A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of
the following laboratory findings should the nurse report to the provider?
a. Hematocrit 30%
i. Is below the expected reference range of greater than 33% for a client who is
pregnant
ii. Low Hct is an indication of anemia
37. A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive
hepatitis B test result. Which of the following actions should the nurse take?
a. Explain to the client that they will receive the hepatitis B immune globulin immediately
i. To decrease the risk of transmission to the fetus
ii. Instruct client that all sexual partners and members of the client’s household
should see their providers to begin prophylactic treatment
38. A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents.
Which of the following instructions should the nurse include?
a. Position the bottle at a 45o angle during feedings
i. To allow the newborn to have more control during feedings and prevent the
swallowing of air
39. A nurse is reinforcing home care safety with the guardian of a newborn prior to discharge. Which
of the following statements by the guardian indicates understanding of the teaching?
a. “I should place my baby’s crib away from windows.”
i. To prevent drafts or entanglement in blinds or drapery
40. A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions should
the nurse identify as an indication that the client understands how to bathe the newborn?
a. The client washes the newborn’s hair before unwrapping them
i. Helps prevent heat loss
41. A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the
following results should the nurse identify as a desirable outcome?
a. Reactive non-stress test
i. Indicates fetal well-being
42. A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the
following actions should the nurse take first?
a. Check the newborn’s blood glucose level
43. A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the
following medications should the nurse expect the provider to prescribe?
a. Methylergonovine
i. Is an oxytocic medication that causes contraction of the smooth muscle of the
uterus, which assists in decreasing the lochia
ii. Should not be administered to clients who have preeclampsia or hypertension
44. A nurse is preparing to administer clindamycin 450 mg PO to a client who has endometritis. The
amount available is clindamycin 150 mg/capsule. How many capsules should the nurse
administer?
a. 3 capsules
i. 450/150 = 3
45. A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine
prenatal visit. Which of the following findings in the data from the client’s medical record should
the nurse report to the provider?
a. Fundal height
i. 20 weeks of gestations should put fundal height at 20 cm plus or minus 2 cm
46. A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus
and excessive vaginal bleeding. Which of the following actions should the nurse take first?
a. Provide fundal massage for the client
i. The greatest risk to this client is postpartum hemorrhage
ii. Fundal massage to increase uterine muscle tone and express blood clots from
the uterus, which will decrease bleeding
47. A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension
with a client who is at 16 weeks of gestation. Which of the following responses by the client
indicates an understanding of the teaching?
a. “I will lie on my left side with my head elevated on a pillow.”
i. Uterus compresses the inferior vena cava in the supine position, which
decreases blood pressure and causes dizziness and fainting
48. A nurse is caring for a client who has received methylergonovine. Which of the following should
the nurse identify and document as an adverse effect of the medication?
a. Hypertension
i. An oxytocic agent that stimulates uterine contractions and is used for
postpartum hemorrhage
ii. Can cause nausea, vomiting, cramping, headache, and dizziness
iii. Report changes in BP due to causing both hypertension AND hypotension
49. A nurse is reinforcing teaching with a client who is at 20 weeks at gestation and reports having
constipation. Which of the following information should the nurse include?
a. Consume 28 g of fiber per day
i. Will help relieve constipation
50. A nurse is collecting data from a client who is in the second trimester of pregnancy. Which of the
following findings should the nurse report to the provider?
a. Frequent uterine contractions
i. Can cause the cervix to open early and subject the client to preterm labor
ATI PN Maternal Newborn 2021-2022 FORM B