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VATI RN Maternal Newborn Assessment Exam Already Graded A+
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A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - correct answer Encourage client who are prescribed methadone to breastfeed. A nurse is caring for a client who received terbutaline subcutaneously. Which of the following findings is an indication the medication was effective? - correct answer Decreased frequency of contractions. A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching regarding situations requiring an amniotomy? - correct answer Placing a fetal scalp electrode. A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication? - correct answer Heart rate 54/min A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the nurse should take to clear the airway obstruction. - correct answer 1. Stand posterior to the client.
A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of the following findings should the nurse identify as a risk factor for developing preeclampsia? - correct answer Rheumatoid Arthritis. A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for deep- vein thrombosis. Which of the following laboratory tests should the nurse monitor? - correct answer International normalized ratio (INR). A nurse is monitoring a client who is in the active phase of labor and has an intrauterine pressure catheter and fetal scalp electrode. Which of the following findings should the nurse expect? - correct answer Montevideo units (MVU) of 220 mm Hg. A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is 10/min. Which of the following actions should the nurse take first? - correct answer Administer oxygen by nonrebreather face mask. A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect? - correct answer Painless vaginal bleeding. A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse report to the provider? - correct answer Episodes of blurred vision. A nurse is assessing a client who is at 8wks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (SATA) - correct answer 1. Tachycardia.
A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching? - correct answer The patent should plan to spend individual time with the older sibling. A nurse is caring for a newborn immediately following birth who has meconium-stained amniotic fluid and exhibits good muscle tone and respiratory efforts. Which of the following actions should the nurse take first? - correct answer Begin suctioning of mouth and nose. A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching? - correct answer I will be certain to consume 29 grams of fiber daily. A nurse is performing a contraction stress test (CST) on a client who is at 40wks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take? - correct answer Allow the labor to progress naturally. A nurse is caring for a newborn who was delivered by cesarean birth 1 min ago and displays some flexion of the extremities, is not cry, has irregular respiratory effort, and has a heart rate of 92/min. The nurse notes grimacing but no crying when rubbing the soles of the newborn's feet. The newborn's skin color is pink with blue extremities. What is the correct Apgar score? - correct answer 1 min is 5. A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level in the abdomen a nurse should expect to find the client's uterus when assessing the fundus. - correct answer C is correct. -Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum. A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. Which of the following actions should the nurse take? - correct answer Wear two pairs of gloves when handling the medication. A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy? - correct answer Amenorrhea.
A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take? - correct answer Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement. A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36wks of gestation. Which of the following actions should the nurse expect to take? - correct answer Administer IV antibiotic prophylaxis. A nurse is reviewing the results of a nonstress test for a client who is at 37wks of gestation. Which of the following findings indicates a reactive nonstress test? - correct answer Fetal heart rate (FHR) accelerations occur with fetal movement. A nurse is providing teaching about nifedipine for a client who is at 34wks of gestation and has gestational HTN. For which of the following adverse effects should the nurse instruct the client to notify the provider? - correct answer Irregular heartbeat. A nurse is assessing a client who is in labor, Which of the following findings should the nurse expect? - correct answer Decrease in blood glucose level. A nurse is assessing a newborn following a circumcision 48hrs ago. The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following? - correct answer Healing. A nurse is performing an initial assessment during a client's first prenatal visit. The client states that her last menstrual period began April 22. Use Nagele's rule to calculate the expected date of birth (EDB). - correct answer 0129 A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia? - correct answer Hypotonia A nurse is teaching a class to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (SATA) - correct answer 1. Management of postpartum pain
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall? - correct answer A client who has an indwelling urinary catheter. A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take? - correct answer Obtain a vaginal culture. A nurse is caring for a client who is in active labor and receiving epidural anesthesia. The client reports feeling nauseated and experiences a blood pressure drop from 125/70 mm Hg to 90/50 mm Hg. Which of the following actions should the nurse take first? - correct answer Turn the client to a lateral position. A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my baby is breech." Which of the following actions should the nurse take first? - correct answer Check fetal heart tones. A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the clients pain? - correct answer Encourage the support person to apply sacral counterpressure. A nurse is caring for a client who had a vaginal delivery 2hrs ago and is reporting increasing perineal pain and pressure. The nurse examines the clients perineum and sees a 4cm (1.6in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following? - correct answer A hematoma A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching? - correct answer I can breastfeed my baby even though I received this immunization. A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the provider? - correct answer Generalized petechiae A nurse is preparing to administer methotrexate 1 mg/kg IM to a client who weights 110lbs and is receiving care for an ectopic pregnancy. Available is methotrexate 25 mg/mL. How many mL should the nurse administer? - correct answer 2
A nurse is caring for a 2 day old newborn who has a bilirubin level of 14 mg/dL and is to begin phototherapy. Which of the following actions should the nurse take? - correct answer Monitor intake and output. A nurse is monitoring a client who is receiving oxytocin to augment labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following actions is the nurse's priority? - correct answer Position the client laterally. A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective? - correct answer Respiratory rate 12/min A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain? - correct answer Encourage the client to listen to music A nurse is providing discharge instructions to the parents of a newborn about bathing. Which of the following statements by the parent indicates an understanding of the instructions? - correct answer We will wash out newborn's face first. A nurse is interviewing a client who is at 10wks of gestation. Which of the following statements by the client should the nurse investigate further? - correct answer I just want to stay in bed all day because nothing interest me anymore. A nurse is planning to use a Doppler device to auscultate fetal heart tones (FHTs) for a client who is at 12wks of gestation. Which of the following actions should the nurse plan to take? - correct answer Count the radial pulse of the client while auscultating FHTs. A nurse is providing teaching for a guardian regarding newborn care. Which of the following statements by the guardian indicates understanding of the teaching? - correct answer I will use a rear-facing car seat for my baby for the first 2 years.
A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due to a postpartum hemorrhage. Which of the following findings is the best indication of adequate perfusion and oxygenation? - correct answer Urinary output. A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse report to the provider? - correct answer Hct 31% A nurse is monitoring the laboratory results for a client who has preeclampsia with severe features. Which of the following results should the nurse expect? - correct answer Increased BUN. A nurse is preparing to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take? - correct answer Warm the newborn's heel for 10mins prior to the puncture. A nurse is reviewing the laboratory report of a client who is at 31wks of gestation and has gestation hypertension. Which of the following laboratory results should the nurse report to the provider? - correct answer Platelet count 99,000/mm3. A nurse is reviewing the laboratory report of a term newborn who is 24hrs old. Which of the following laboratory results should the nurse report to the provider? - correct answer Glucose 35 mg/dL. A nurse is assessing a newborn who was born 15mins ago. Which of the following actions should the nurse take? - correct answer Count the respiratory rate for 60 seconds. A nurse is assessing a client who has genital herpes. Which of the following findings should the nurse expect? - correct answer Ulcerated lesions on the labia.