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2024 ATI RN MATERNAL NEWBORN PROCTORED
EXAM WITH NGN 250 QUESTIONS & CORRECT
ANSWERS GRADED A+ WITH RATIONALES
- A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A. Painless red vaginal bleeding Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. B. Increasing abdominal pain with a nonrelaxed uterus Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances. C. Abdominal pain with scant red vaginal bleeding Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of abdominal pain. D. Intermittent abdominal pain following passage of bloody mucus Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor.
The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to as the "bloody show."
- A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client. B. Notify the client‟s provider. Rationale: These are expected findings, so there is no need to notify the provider. C. Increase the frequency of fundal massage. Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal massage is not indicated at this time. D. Encourage the client to empty her bladder. Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated, this would be an indication of a distended bladder and the client should be encouraged to void to prevent uterine atony.
- A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A. "It's a minor inconvenience, which you should ignore." Rationale: This is a nontherapeutic response that disregards the client‟s concern and offers unwarranted reassurance. B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during pregnancy. C. "There is no way to predict how long it will last in each individual client." Rationale: This is a nontherapeutic response that does not provide appropriate information to the client. D. "It occurs during the first trimester and near the end of the pregnancy." Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? E. Shortly after giving birth Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome. F. In the third trimester Rationale: Because the rubella vaccine contains a live virus, immunizing the client at this point in pregnancy would put her fetus at risk for developing rubella syndrome. G. Immediately Rationale: Because the rubella vaccine contains a live virus, immunizing the client during the first trimester would put the fetus at risk for developing a severe manifestations of rubella syndrome. H. During her next attempt to get pregnant Rationale: Rubella immunization must be given at least 28 days prior to pregnancy to assure that the developing fetus is not exposed to the virus and put at risk for rubella syndrome.
- A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?
A. "What part of the exam makes you most nervous?" Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns. B. "Don't worry, I will be with you during the exam." Rationale: This closed-ended nontherapeutic response discounts the client's feelings and does not encourage further discussion. C. "All you need to do is relax." Rationale: This closed-ended nontherapeutic response does not address the client's concerns and does not encourage further discussion. It blocks communication by using a cliché and false reassurance. D. "A pelvic exam is required if you want birth control pills." Rationale: This statement fails to address the client‟s feelings that she shared with the nurse. It blocks communication and does not encourage further discussion.
- A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? A. Two veins and one artery Rationale: This is not the correct combination of vessels.
B. One artery and one vein Rationale: This is not the correct combination of vessels. C. Two arteries and one vein Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. D. Two arteries and two veins Rationale: This is not the correct combination of vessels.
- A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A. A male condom Rationale: This method of contraception has 11 to 16 failures for every 100 users. B. An intrauterine device (IUD) Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most
D. The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.
- A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? A. Insert an indwelling urinary catheter. Rationale: An indwelling urinary catheter can be inserted in the delivery room just prior to delivery. This is not the priority nursing action. B. Initiate IV access. Rationale: Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.
D. Excessive uterine enlargement C. Witness the signature for informed consent for surgery. Rationale: Rationale C. This is not the nurse's priority action at this time. A family member can sign the consent form if needed. D. Prepare the abdominal and perineal areas. Rationale: Skin preparation can be delayed until just prior to a cesarean delivery. This is no the priority nursing action. 12 .AA nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? A. Rapid decline in human chorionic gonadotropin (hCG) levels Rationale: A client who has a hydatidiform mole usually has an elevated serum hCG level. B. Profuse, clear vaginal discharge Rationale: A client who has a hydatidiform mole often has vaginal bleeding later in the pregnancy. This discharge can be dark brown, bright red, scant, or profuse. C. Irregular fetal heart rate Rationale: When a client has a hydatidiform mole, fetal heart tones are not heard since there is no developing fetus.
This addresses the client‟s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. D. "This is a concern, but strabismus is easily treated with patching." Rationale: This is an inappropriate statement by the nurse because it offers unwarranted reassurance. The nurse is making an assumption that that should be addressed by the provider. 14 .AA nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? A. Immediately report the situation to the client's provider and prepare the client for induction of labor. Rationale: The fetus might not be moving because it is asleep, or there might be another benign reason. B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. Rationale: Having the client walk is not likely to promote fetal movement. C. Offer the client a snack of orange juice and crackers. Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement. D. Turn the client onto her left side.
Rationale: Turning the client onto her left side increases the placental perfusion of oxygen to the fetus, but the FHR of 130 to 150/min is not indicative of fetal distress. 15 .AA nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. Rationale: Calling the provider may be appropriate; however, this is not the priority intervention. B. Position the client with one hip elevated. Rationale: Based on Maslow‟s hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess. C. Ask the client if she needs pain medication. Rationale:
17 .AA nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Whichof the following is the priority nursing assessment for this client? A. Temperature Rationale: Although the use of magnesium sulfate in a client experiencing preterm labor can result in hypothermia, this assessment is not the nurse‟s priority assessment. B. Fetal heart rate (FHR) Rationale: It is important to monitor the FHR of any client experiencing labor; however, this assessment is not the nurse‟s priority assessment. C. Bowel sounds Rationale: Although the use of magnesium sulfate in a client experiencing preterm labor can result in ileus, this assessment is not the nurse‟s priority assessment. D. Respiratory rate Rationale: Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous
system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate.
- A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn‟s plan of care? A. Observe for meconium in respiratory secretions. Rationale: When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery. B. Monitor for hyperglycemia. Rationale: Newborns who are SGA have difficulty maintaining normal blood glucose levels and are at high risk for hypoglycemia, not hyperglycemia. C. Identify manifestations of anemia. Rationale: Infants who are SGA have polycythemia, which means there are too many red blood cells, rather than anemia, in which there are too few red blood cells.
D. Avoid foods containing aspartame. Rationale: Aspartame in the diet has no effect on the incidence of neural tube defects in a fetus. Clients who have phenylketonuria should be advised to avoid aspartame since it contains phenylalanine.
- A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? A. Vaginal intercourse can be resumed after 2 weeks. Rationale: The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge. B. Products of conception will be present in vaginal bleeding. Rationale: The products of conception are surgically removed during a D&C. C. Increased intake of zinc-rich foods is recommended. Rationale: The client is encouraged to consume foods high in iron and protein to replace red blood cells and repair uterine tissue. D. Aspirin may be taken for cramps. Rationale: Aspirin for pain management of cramps should be avoided because of its anticoagulant property. NSAIDS, such as ibuprofen, are recommended as they are an antiprostaglandin
agent and reduce the discomfort of cramping. 21 .AA nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? A. 1+ pitting sacral edema Rationale: This finding is consistent with the diagnosis of preeclampsia. B. 3+ protein in the urine Rationale: This finding indicates proteinuria, a finding that is consistent with the diagnosis of preeclampsia. C. Blood pressure 148/98 mm Hg Rationale: This finding is consistent with the diagnosis of preeclampsia. D. Deep tendon reflexes of + Rationale: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex.
