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A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth
...
Unilateral breast pain
i
...
(Pg
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Persistent abdominal striae
i
...
Lochia alba
i
...
WBC count 12,000/mm3
2
...
Which of the following findings should the nurse report to the
provider?
a
...
Deep tendon reflexes of 2+
c
...
Severe preeclampsia: consists of blood pressure that is 160/110 mmHg or greater, proteinuria greater than 3+, oliguria, elevated serum
creatinine greater than 1
...
(pg
...
Hemoglobin 13 g/dL
3
...
Which of the following responses by the nurse is appropriate?
a
...
”
b
...
”
c
...
”
d
...
”
i
...
(Pg 61) ATI Maternal newborn 2
4
...
Which of the following information should the nurse include? (pg 76)
a
...
”
i
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“Your contractions will become temporarily regular
...
“You will have bloody show
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Sign of true labor
d
...
”
i
...
A nurse manager is revising a maternal unit policy to ensure proper identification of newborns
...
Check the newborn’s identification using the crib card
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Replace the infant’s identification band after his name has been recorded
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Require visitors to wear an identification band
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Obtain an imprint of the infant’s feet prior to taking him to the nursery
...
A nurse is caring for a client who delivered by cesarean birth 6 hr ago
...
Which of the following actions should the nurse take?
a
...

b
...

c
...

i
...
Evaluate urinary output
...
Encourage the client to empty her bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony
...
Frequent voiding of less than 150 mL of urine is indicative of urinary retention with overflow
...
A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts
...
Wear nipple shields during the feeding
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Use a breast binder for 2 days
...
Use plastic-lined breast pads
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Apply cabbage leaves after feedings
...
A nurse is calculating estimated date of birth using Naegele’s rule for a client who is pregnant and whose last menstrual cycle started June 21
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March 14
b
...
March 28
i
...
April 4
9
...
Which of the following actions should the nurse take?
a
...

b
...

i
...
Instruct the client that an autopsy should be performed within 24 hr
...
Prepare the client for what to expect the fetus to look like
...
A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet
...
” Which of the following actions
should the nurse take?
a
...

b
...

c
...

d
...

11
...
Which of the following findings should prompt the nurse to reassess the client?
a
...
An urge to have a bowel movement during contractions
c
...
Progressive sacral discomfort during contractions
12
...
Which of the following findings should the nurse report
to the provider?
a
...
8 g/dL
i
...
Urine protein concentration 200 mg/24 hr
i
...

ii
...
It’s a maternal adaptation to possibly have proteinuria
...

c
...
8 mg/dL
i
...
Platelet count 60,000/mm3
i
...
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant
...
Lay the tape measure horizontally over the middle of the client’s abdomen
...
Place the client in a left-lateral position to obtain the measurement
...
Ensure that the client has a full bladder before taking the measurement
...
External abdominal ultrasound
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Measure from the upper border of the pubis to the upper border of the fundus
...
A nurse is caring for a client who is at 20 weeks of gestation and reports constipation
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Include 18 g of fiber in the diet each day
...
Total fiber AI is 25 g/day for women and 38 g/day for men
...
Drink 2 to 3 L of water each day
...
Pg
...
Suggest that the client increase roughage and fluid intake in diet to assist with discomforts of constipation
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Add 30 mL of mineral oil to each meal
...
Tale 60 mL of magnesium hydroxide once daily
...
A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation
...
Which of the following terms should the nurse use to
document this finding?
a
...
Probable sign
b
...
Soft, muffled, blowing sound produced by the blood rushing through the umbilical vessels and synchronous with the fetal heart sounds
...
Quickening
d
...
Probable sign
ii
...
A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses
...
Allow parents to enter the nursery if they are wearing a mask
...
Pg
...
Cover gowns or special uniforms are used to avoid direct contact with clothes
...
Place newborn bassinets at least 3 feet apart
...
Pg
...
Provide individual bassinets, equipped with a thermometer, diapers, T-shirts, and bathing supplies
...
All personnel who care for newborn should scrub up with antimicrobial soap from elbows to fingertips before entering the nursery
...
Place the newborn’s foot on a sterile field during a heelstick
...
Maintain airborne precautions in the nursery
...
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion
...
Which of the following medications should the nurse administer?
a
...
Vitamin K reversal
b
...
APAP reversal
c
...
Heparin reversal
d
...
Admin for magnesium toxicity
ii
...
A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void
...
Apply suprapubic pressure
...
Administer a diuretic to the client
...
Insert an indwelling urinary catheter
...
Encourage the client to void in the shower
...
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus
...
“Mothers will receive prophylactic treatment with acyclovir prior to delivery
...
Because no treatment for cytomegalovirus exists, tell the client to prevent exposure by frequent hand hygiene before eating, and after
handling infant diapers and toys
...
“Transmission can occur via the saliva and urine of the newborn
...
Cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, a virus found in semen, cervical
and vaginal secretions, breast milk, placental tissue, urine, feces, and blood
...
(pg
...
There is no treatment for cytomegalovirus
...
“This infection requires airborne precautions are initiated for the newborn
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Transmitted by droplet infection
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“Lesions are visible on the mother’s genitalia
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Asymptomatic or mononucleosis-like manifestations
20
...
Which of the following is the initial laboratory testused to
evaluate this condition?
a
...
Complete blood count
i
...
Pg 58
c
...
Urinalysis for ketones and acetones (breakdown of protein and fat) is the most important initial laboratory test: Elevated urine specific gravity
...
1
...
030
d
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A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks gestation
...
There are three tabs that contain separate categories of
data
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Administer ceftriaxone IM
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Neisseria gonorrhoeae
ii
...
Administer rubella vaccine
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1:8 is aight
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Obtain a maternal serum alpha-fetoprotein specimen
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Used to rule out Down syndrome (low level) and neural tube defects (high level)
...

d
...

22
...
Which of the following statements should the nurse
include in the teaching? (pg 4)
a
...
”
i
...
“You should take your temperature before getting up for the day
...
Measure oral temperature prior to getting out of bed each morning to monitor ovulation
ii
...
“You should abstain from intercourse when your temperature is above 100 F
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“Your temperature may increase slightly immediately prior to ovulation
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Temperature may DROP slightly before ovulation
23
...
Which of the following instructions should the
nurse include in the teaching?
a
...
”
i
...

b
...
”
c
...
”
d
...
”
24
...
Which of the following goals should the nurse identify for the client to
accomplish during the taking-in phase of postpartum adjustment?
a
...

i
...
125)
1
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Resumption of role (intimate partner, individual)
b
...

i
...
Focus on meeting personal needs
c
...

i
...
Focus on baby care and improving caregiving competency
d
...

i
...
Focus on baby care and improving caregiving competency
25
...
Which of the following
instructions should the nurse include in the teaching?
a
...
”
i
...
(pg
...
“Count your baby’s movements daily
...
Preeclampsia affects the baby; the mom may not be able to supply enough oxygen to the infant = baby not moving = indicates that the baby is
not well-oxygenated
...
“Reduce your calcium intake to less than 1 gram per day
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“Alternate arms each time you check your blood pressure
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A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS)
...
She asks the nurse why the test was not conducted earlier in her pregnancy
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“We need to know if you are positive for GBS at the time of delivery
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Obtain a vaginal/anal culture at 35 to 37 weeks of gestation to assess for GBS infection
...
20
ii
...
Pg
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“There was no indication of GBS in your earlier prenatal testing
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Manifestations: premature rupture of membranes, chorioamnionitis, UTI, maternal sepsis
c
...
”
i
...

ii
...

d
...
”
27
...
Which of the following clinical findings should the nurse report to
the provider?

�a
...
Simian line
ii
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Transient circumoral cyanosis
i
...
Rust-stained urine
i
...

d
...
Subconjunctival hemorrhages can result from pressure during birth
...
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock
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Respiratory rate 18/min
i
...
Someone with hypovolemic shock is tachypneic
b
...
Manifestations of hypovolemic shock: tachypnea, hypotension, pallor, and cool, clammy skin
...
Urinary output 30 mL/hr
d
...
A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy
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“You can take 400 milligrams of ibuprofen for discomfort
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“You should take 600 micrograms of folic acid per day
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Majority of birth defects occur between 2 and 8 weeks of gestation
...
19
ii
...
Pg
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“You can take black cohosh once a day for insomnia
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OTC not to be taken during pregnancy
d
...
”
i
...
3 L) of fluid are recommended daily
30
...
Which of the following
interventions should the nurse include in the plan?
a
...

i
...
Pg
...
Keep the IV line open and increase the rate of IV fluid to 200 mL/hr unless contraindicated
...
101
b
...

i
...
Pg
...
Limit IV intake to 4 L per 24 hr
...
Titrate the infusion rate by 4 milliunits/min
...
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation
...
“You should expect your uterus to double in size
...
“Your stomach will empty rapidly
...
Slowed stomach emptying
...
“Your nipples will become lighter in color
...
Darkened areolae (pg
...
“You should anticipate nasal stuffiness
...
A common discomfort of pregnancy
...
22)
32
...
Which of the following actions should the
nurse take?
a
...

i
...
(pg
...
Allow the medication to reach room temperature prior to administration
...
Instruct the client to avoid urinary elimination until after administration
...
Assist the client to void prior to the procedure
...
Place the client in a semi-Fowler’s position for 1 hr after administration
...
The client should remain in a side-lying position
...
A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease
...
How many tablets should the nurse administer? (Round the answer to the nearest whole number
...
Do not
use a trailing zero
...
2g → 2000 mg
b
...
A nurse in a prenatal clinic is caring for a group of clients
...
A client who is at 37 weeks of gestation and has an L/S ratio 2:1
i
...
34)
ii
...
2
...
A client who is at 35 weeks of gestation and has a biophysical profile of 6
i
...
30)
ii
...
LESS THAN 4: abnormal, strongly suspect chronic fetal asphyxia
c
...
NEGATIVE CST (Normal finding): Indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR
d
...
A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work
...
“Thawed breast milk that is unused can be refrozen
...
Do not refreeze thawed milk
...
“Breast milk can be stored at room temperature for up to 12 hours
...
Breast milk can be stored at room temperature under very clean conditions for up to 8 hr
c
...
”
i
...
(pg
...
“Thawed breast milk can be refrigerated for up to 72 hours
...
Thawing the milk in the refrigerator for 24 hr is the best way to preserve the immunoglobulins present in it
...
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord
...
Erythema toxicum
i
...

b
...
Telangiectatic nevi
i
...
Flat pink or red marks that easily blanch and are found on the back of the neck, nose, upper eyelids, and middle of the forehead
...

d
...
Bruises or petechiae may be present on the head, neck, and face of an infant born with a nuchal cord (cord around the neck)
...
Expected Findings: Localized discoloration, ecchymosis, petechiae, and edema over the presenting part are seen with soft-tissue injuries
...
A nurse is assessing a newborn upon admission to the nursery
...
Length from head to heel of 40 cm (15
...
45 to 55 cm (18 to 22 in)
b
...
Bulging fontanels can indicate increase intracranial pressure, infection, or hemorrhage
c
...
8) smaller than the head circumference
i
...
8 cm
d
...
Respiratory distress: nasal flaring, grunting, retractions, gasping, and labored breathing
...
164)
38
...
After the head emerges, the nurse palpates the cord around the
newborn’s neck
...
Apply fundal pressure
...
Place the client in the knee-chest position
...
Reposition to relieve pressure on the cord (pg
...
Apply a water-based lubricant to the cord
...
Slip the cord over the newborn’s head
...
A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device
...
Wash the circumcision site with mild soap and water 24 hr following the procedure
...
Change the newborn’s diaper at least every 4 hr, and clean the penis with warm water with each diaper change (p
...
Take off the plastic bell 2 hr after the procedure
...
Plastibell drops off after 5 to 7 days
c
...

i
...
178)
d
...

i
...


40
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Which of the following
instructions should the nurse include in the teaching?
a
...
”
b
...
”
c
...
”
i
...

d
...
”
41
...
2 mg orally to a client who is 2 hr postpartum and has a boggy uterus
...
Respiratory rate 14/min
b
...
Urine output 100 mL in 3 hr
d
...
A nurse is caring for four newborns
...
A newborn who has molding with overlapping suture lines
b
...
Vaginal blood-tinged discharge can occur in female newborns, which is caused by maternal pregnancy hormones
...

(p
...
A newborn who has a high-pitched cry with exaggerated Moro reflex
i
...
183)
ii
...
A male newborn who has a scrotal edema
i
...

43
...
Which of the following responses should the nurse take?
a
...
”
i
...
“You cannot have an amniocentesis until you are at least 35 years of age
...
“This procedure determines if your baby has genetic or congenital disorders
...
“Your provider will schedule a chorionic villus sampling to determine the sex of your baby
...
CVS is an earlier diagnosis of any abnormalities including Down syndrome and neural tube defects
44
...
The client reports no relief in perineal pain following the administration of
oxycodone/acetaminophen
...
Reposition the client
...
Need to verify possible cause of pain first?
b
...

c
...

d
...

45
...
For which of the following potential complications of gonorrhea
should the nurse monitor?
a
...
Vaginal laceration during birth
c
...
Oligohydramnios
46
...
The nurse observes late decelerations of the fetal heart rate on the external fetal monitor
...
Decrease the rate of IV fluids
...
Increase the rate of IV fluid administration
b
...

i
...
Administer oxygen via a face mask
...
Administer o2 by mask at 8 to 10 L/min via nonrebreather face mask
d
...

47
...
Which of the following actions should the nurse take prior to the
beginning of surgical correction?
a
...

b
...

c
...


d
...

48
...
The client has a hemoglobin level of 9
...
Which of the following actions should the nurse take?
a
...

b
...

c
...

d
...

49
...
Which of the following
findings should the nurse report to the provider?
a
...
Absence of clonus
c
...
Urine output 20 mL/hr
50
...
Which of the following actions should the nurse take?
a
...

b
...

c
...

d
...

51
...
Which of the following actions should the nurse take first?
a
...

b
...

c
...

d
...

52
...
Which of the following food
selections has the highest fiber content per cup?
a
...
Oatmeal
c
...
Asparagus
53
...
The nurse should observe the client for which of the following complications?
a
...
Hyperemesis
c
...
Hemorrhage
54
...
The client expresses concern about preparing her 2-yearold- child for a new sibling
...
“Move your toddler to his new bed 2 months before the baby comes home
...
“Let the toddler see you carrying the baby into the home for the first time
...
“Avoid bringing your toddler to prenatal visits
...
“Required scheduled interactions between toddler and the baby
...
A nurse is assessing current medication use with a client who is at 6 weeks of gestation
...
Azithromycin
b
...
Diphenhyamine
d
...
A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position
...
Bottom right square?? Yah…
...
LLQ
57
...
The nurse should inform the client that it is safe for her to receive
which of the following immunizations during pregnancy?
a
...
Rubella
c
...
Rubeola

58
...
Which of the following findings should the nurse report to
the provider?
a
...
9 mg/dL
b
...
Fasting blood glucose 180 mg/dL
d
...
A nurse is caring for a client who is at 35 weeks of gestation and is on bed rest due to preeclampsia
...
Maintain NPO status
b
...
Keep the lights dimmed in the room
...
Auscultate fetal heart tones twice per day
60
...
” Which of the
following responses should the nurse make?
a
...
”
b
...
”
c
...
”
d
...
”
61
...
Identify the
sequence the nurse should follow when performing suction with a bulb syringe
...
Lace the bulb syringe in the newborn’s mouth (2)
�b
...
Assess the newborn for reflex bradycardia (4)
d
...
A nurse is receiving report on four postpartum clients
...
A client who reports abdominal pain during breastfeeding
b
...
A client who has urine output of 250 mL in 6 hr
i
...
6 hr= 180mL
d
...
A nurse is teaching a client about using a diaphragm
...
“Insert the diaphragm up to 12 hours before intercourse
...
Insert up to 6 hr before intercourse (pg 5)
b
...
”
i
...
“Replace the diaphragm every 2 years
...
“Use 2 teaspoons baby oil to lubricate the diaphragm before insertion
...
Use spermicidal cream/jelly (pg 5)
64
...
The nurse determines client is 80% effaced
and 8 cm dilated
...
Hyperemesis gravidarum
�b
...
Incompetent cervix
d
...
A nurse is providing vehicle safety education to parents of a premature newborn
...
“You should secure your newborn’s car seat at a 60 degree angle
...
45 degree angle to prevent slumping (ATI peds 2016 prac)
b
...
”
c
...
”
i
...
“Position the retainer clip at the level of your newborn’s abdomen
...
A nurse is providing discharge instructions to a client who is breastfeeding her newborn
...
Allow the baby to feed at least every 3 hours
b
...
Expect two to four wet diapers every 24 hrs
d
...
A nurse is assessing a client who is 2 days postpartum
...
Hypotonic uterus
b
...
Platelet count 370,000/mm3
d
...
A nurse is reviewing the medical record of a client who had vaginal delivery 3 hr ago
...
History of human papillomavirus
�b
...
Labor induction with oxytocin (pg 135)
i
...

d
...
948 kg (6 lb 8 oz)
�e
...
135)
69
...
Which of the following findings should the nurse report to the provider?
a
...
5 degrees C (97
...
Blood pressure 80/50 mm Hg
c
...
Heart rate 72/min
70
...
Which of the following
findings should the nurse report to the provider? (SATA)
a
...
Report if respirations <12/min
ii
...
Urine output 130 mL /4 hr
i
...
Pg 61
c
...
Sign of magnesium toxicity
ii
...
Fetal heart rate 20/min(typo its 120)
e

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