Download (NGN) ATI RN MATERNAL NEWBORN PROCTORED EXAM TESTBANK|REVISED & UPDATED SPRING 2025. Qs&As and more Exams Nursing in PDF only on Docsity!
(NGN) ATI RN MATERNAL NEWBORN PROCTORED
EXAM TESTBANK|REVISED & UPDATED SPRING
SESSION 2025|350+Qs and As WITH RATIONALES
A nurse is teaching a client who is at 12 wks gestation and has HIV. What statementshould the nurse include in the teaching? a. you will be in isolation after delivery b. abstain from sexual intercourse throughout pregnancyc. breastfeed your newborn to provide passive immunity d. you should continue to take zidovudine throughout the pregnancy Rationale: - can be transmitted through breastfeeding
- she can continue to have sex The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn. A nurse is providing teaching to a client who is at 8 wks gestation about manifestationsto report to the provider during pregnancy. What info should the nurse include in the teaching? a. nausea upon awakeningb. blurred or double vision c. increase in white vaginal discharge d. leg cramps when sleeping - ANS:-b. blurred or double vision A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2min which last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take? a. Decrease the dose of oxytocin by half b. administer oxygen via nonrebreather mask c. decrease the infusion rate of the maintenance IV fluid d. administer terbutaline 0.25mg subq - ANS:-a. decrease the dose of oxytocin byhalf Rationale The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole. A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take? a. prepare the client for emergency c-section b. perform endotrach suctioning as soon as the fetal head is delivered c. prepare equipment needed for newborn resuscitation
d. prepare the client for an ultrasound exam - ANS:-c. prepare equipment neededfor newborn resuscitation Rationale The nurse should ensure that all supplies and equipment needed for resuscitation of thenewborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery. A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider? a. insert a large- bore IV catheter b. perform a vaginal exam c. perform continuous external fetal monitoring d. obtain a blood sample for lab testing - ANS:-b. perform a vaginal exam Rationale When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta andincreased bleeding. A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstresstest. The FHR is 130 without accelerations for the past 10 min. What action should thenurse take? a. request a script for an internal fetal scalp electrodeb. auscultate the FHR with a doppler transducer c. report the nonreactive test result to the provider immediately d. use vibroacoustic stim on the client's abd for 3 seconds - ANS:-d. use vibroacoustic stim on the client's abd for 3 seconds Rationale The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetalactivity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR. A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take? a. instruct the client to obtain a rubella immunization after deliveryb. request a script for an antibiotic until delivery c. inform the client that she will have to deliver via c-section d. administer a dose of Pho(D) immune globulin - ANS:-a. instruct the client toobtain a rubella immunization after delivery
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant andasks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will be used to confirm her pregnancy? a. urine test for presence of HCG b. urine test for the presence of HCS c. blood test for presence of estrogen d. blood test for the amount of circulating progesterone - ANS:-a. urine test forpresence of HCG A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? a. palpable fetal movementb. amenorrhea c. chadwick's sign d. positive pregnancy test - ANS:-a. palpable fetal movement A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect? a. renal agenesis b. atrial septal defect c. spina bifida d. hydrocephalus - ANS:-a. renal agenesis A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvicfracture due to blunt abd trauma. What findings should the nurse expect? a. uterine contractions b. bradycardia c. seizures d. bradypnea - ANS:-a. uterine contractions The nurse should expect the client to be experiencing uterine contractions due toabdominal trauma. A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings should the nurse expect? a. hypothermia b. dark brown vaginal discharge c. fetal heart tones d. decreased urinary output - ANS:-b. dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority? a. 480 mL urine output in 24 hrs b. 1+ protein in the urine c. +2 edema of the feet d. BP 144/92 - ANS:-a. 480 mL urine output in 24 hrs A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in thefirst trimester. What info should the nurse include in the teaching? a. you will need to have a full bladder during the ultrasound b. you will have a non stress test prior to the ultrasound c. the ultrasound will determine the length of your cervix d. you will experience uterine cramping during the ultrasound - ANS:-a. you willneed to have a full bladder during the ultrasound MY ANS: The nurse should tell the client that a full bladder helps to lift the gravid uterus out of thepelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus. A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect? a. decreased urinary outputb. fetal distress c. dark red vaginal bleeding d. increased platelet count - ANS:-c. dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimaldark red vaginal bleeding. A nurse is caring for a client whose last menstrual period began july 8. Using Nagelesrule, the nurse should identify the client's estimated DOB as what? a. oct 15 b. april 15c. oct 1 d. april 1 - ANS:-b. april 15 A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identifyas the cause of late decels? a. umbilical cord compressionb. fetal head compression c. uteroplacental insufficiency
have the client drink orange juice d. palpate the uterus for fetal movement - ANS:-a. auscultate for a FHR Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an externalfetal monitor. This is the priority nursing action. A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia.What assessment provides the most accurate info regarding the client's fluid and electrolyte status. a. daily wt b. bp c. severity of edema d. I&O - ANS:-a. daily wt A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching? a. 10 fetal movements per hourb. mild constipation c. vaginal bleeding d. nasal congestion - ANS:-c. vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor. A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What info should the nurse include? a. you will have to undergo a c-section birth because of the fibroid b. the fibroid can increase the risk for postpartum hemorrhagec. the fibroid will shrink during pregnancy
d. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid - ANS:- b. the fibroid can increase the risk for postpartum hemorrhage A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate? a. you should drink 1 ounce of mineral oil q morning b. you should eat at least 3 ounces of red meat/day c. you should walk for at least 30 minutes q day d. you should stop taking your prenatal - ANS:-c. you should walk for at least 30 minutes q day The nurse should encourage the client to participate in moderate physical activity, suchas walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. A nurse is planning care for a newborn who is receiving phototherapy for an elevatedbilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal regionb. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings - ANS:-c. use photometer tomonitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure thenewborn is receiving the appropriate amount to be effective. A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feetthat are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanketc. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings - ANS:-b. place the nakednewborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his motherhelps stabilize his temperature and promotes bonding. A nurse is caring for a newborn immediately following delivery. What actions should thenurse take first? a. place the newborn directly on the client's chestb. administer erythromycin ophthalmic ointment c. give the newborn vit K IM
The nurse should continue routine monitoring because the newborn's assessmentsfindings indicate he is adapting to extrauterine life. placing in sidelying or supine A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillowc. have the client drink fluids through a straw d. assist the client to ambulate in the hallway - ANS:-d. assist the client to ambulatein the hallway Walking can help stimulate peristalsis, which will promote expulsion of gas. A nurse is caring for a newborn who is premature at 30 wks gestation. What findingshould the nurse expect? a. heel creases covering the bottom of the feetb. good flexion c. abundant lanugo d. dry, parchment-like skin - ANS:-c. abundant lanugo Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders,pinnas, and forehead. A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclerac. resp rate 50 d. cbg 60 - ANS:-b. jaundice of the sclera If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in highlevels of bilirubin that can cause damage to the neonatal brain. A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include? a. discard unused refrigerated formula after 72 hrs b. prop the bottle with a blanket for the last feeding of the day c. dilute ready-to-feed formula if the newborn is gaining wt too quickly d. boil water for powdered formula for 1 - 2 min - ANS:-d. boil water for powderedformula for 1 - 2 min
The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination. A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rateb. bp c. fundal consistency d. output - ANS:-c. fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective. A nurse is caring for a newborn who is premature in the neonatal ICU. what actionshould the nurse take to promote development? a. discourage the use of pacifiers b. position the naked newborn on the parents bare chest c. provide frequent periods of visual and auditory stimulation d. rapidly advance oral feedings - ANS:-b. position the naked newborn on theparents bare chest A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? select all a. oxytocin infusion b. prolonged labor c. mag sulfate infusion d. small for gestational age newborn e. distended bladder - ANS:-b. prolonged labor
A newborn who is born at 39 weeks of gestation is full-term and should have normal,smooth skin with good turgor and the presence of subcutaneous fat pockets. A postmature newborn, greater than 42 weeks of gestation, will have dry, cracked skin with a wrinkled appearance. A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3 - 4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe - ANS:-a. this will resolve within 3 - 6 wks without treatment A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterusb. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area - ANS:-c. slow trickleof bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration. A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification? a. initiate bedrest with HOB elevatedb. initiate high-fiber diet for client c. monitor clients wt wkly d. monitor client's I&O - ANS:-c. monitor clients wt wkly The nurse should weigh the client daily to monitor for fluid overload. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching?a. stand under hot shower with your breasts exposed b. place ice packs on your breastsc. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra - ANS:-b. place ice packs on your breasts The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body producesmilk.
A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1 - 2 hr of delivery? a. poractant alpha b. rotavirus immunization c. naloxone d. erythromycin ophthalmic ointment - ANS:-d. erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth. A nurse is caring for a newborn who weighs 4lb. How many kg does the newbornweigh? - ANS:-1. A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina.What following statements should the nurse make? a. blood pools in the vagina when you are lying a bed b. the amount of blood flow will increase during the first few days after giving birthc. you might have retained placental fragments in your uterus d. you might have a damaged blood vessel - ANS:-a. blood pools in the vagina when you are lying a bed In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia. A nurse is providing teaching to a client who is planning to breastfeed her newborn.What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milkb. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore
- ANS:-c. it is normal for my baby to sometimes feed every hr for severalhours in a row Cluster feeding is an expected finding for newborns who are breastfeeding. The mothershould follow her newborn's cues and feed her 8 to 12 times per day A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside? a. naloxone b. protamine sulfate c. calcium gluconate d. atropine - ANS:-c. calcium gluconate
Allowing the newborn to suck on a pacifier is an effective form of nonpharmacologicalpain management. A nurse is assessing a client on the first postpartum day. Findings include fundus firmand one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take? Report the vital signs to the provider. Massage the fundus. Ask the client when she last voided. Administer an oxytocic agent. - ANS:-Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, thefundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void. A nurse is preparing to administer naloxone to a newborn. Which of the followingconditions can require administration of this medication? IV narcotics administered to the mother during labor Maternal drug use Hyaline membrane disease Meconium aspiration - ANS:-IV narcotics administered to the mother during labor The nurse should administer naloxone to reverse respiratory depression due to acutenarcotic toxicity, which can result from IV narcotics administration during labor. A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make? "An epidural given too early during labor can cause maternal hypertension." "An epidural given too early during labor will not be effective in active labor." "An epidural given too early can cause fetal depression." "An epidural given too early can prolong labor." - ANS:-An epidural given too earlycan prolong labor Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervoussystem. Therefore, it will take longer for the cervix to dilate and efface. A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client?
"You should eat some crackers before rising from bed in the morning.""You should eat foods served at warm temperatures." "You should sip whole milk with breakfast." "You should brush your teeth immediately after meals." - ANS:-You should eat some crackers before rising from bed in the morning Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) inthe mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant. A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin? While the client is in labor Following an episode of influenza during pregnancy Prior to a blood transfusion At 28 weeks of gestation - ANS:-At 28 weeks of gestion The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production. A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicatestoxicity due to the magnesium sulfate therapy? Respiratory depression Hypothermia Hypoglycemia Jaundice - ANS:-Respiratory depression Magnesium sulfate can cause respiratory and neuromuscular depression in thenewborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression. A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? Promoting maternal-newborn bonding Tight swaddling of the newborn Small frequent feedings Frequent stimulation - ANS:-Frequent stimulation
intercourse until cultures are negative." "If both you and your partner are treated simultaneously, you may continue to engage insexual intercourse." "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative." - ANS:-You and your partner need to take the medication and use a condom during intercourse until cultures are negative Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with anunpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment towork, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated. A nurse is caring for four newborns. Which of the following newborns is at greatest riskfor hypoglycemia? A newborn who is large for gestational ageA newborn who has an Rh incompatibility A newborn who has pathologic jaundice A newborn who has fetal alcohol syndrome - ANS:-A newborn who is large forgestational age Large for gestational age (LGA) newborns are those newborns whose weight is at orabove the 90th percentile. One of the most common etiologies of LGA newborns is amother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia. A nurse is caring for a client who is 2 hours postpartum. The nurse notes the client'sperineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? Check for a full bladder. Massage the fundus. Measure vital signs. Administer carboprost IM. - ANS:-Massage the fundus
The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. Thus, the greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first. A nurse is caring for a client whose membranes have ruptured and is in active labor.The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? Turn the client onto her left side. Palpate the client's uterus. Administer oxygen to the client. Increase the client's IV fluids. - ANS:-Turn the client onto her left side Late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side willrelieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply. A nurse is planning care for a client who has a prescription for oxytocin. Which of thefollowing is a contraindication for the use of this medication? Prolonged rupture of membranes at 38 weeks of gestationIntrauterine growth restriction Postterm pregnancy Active genital herpes - ANS:-Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal.Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection. A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of thefollowing clinical findings should the nurse expect? Extended periods of sleep Poor muscle tone Respiratory rate 50/min Exaggerated reflexes - ANS:-Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.
