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ATI MATERNAL NEWBORN PROCTORED
RETAKE 2024 RETAKE EXAM COMPLETE
EXAM
A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? A. Administer magnesium sulfate 4 g IV bolus B. Insert an indwelling urinary catheter C. Give oxygen at 10 L/min via face mask D. Keep the environment quiet and the lights dimmed - C. Give oxygen at 10 L/min via face mask A nurse is caring for a client who is at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep all 4 side rails up while the client is in bed B. Monitor the fetal heart rate every hour C. Insert an indwelling urinary catheter D. Check the cervix prior to analgesic administration - D. Check the cervix prior to analgesic administration A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? A. "A fetal stethoscope can first detect your baby's heart rate at 22 weeks." B. "After week 16, we can see if your baby is a boy or a girl." C. "A Doppler device can detect your baby's heart rate at 12 weeks." D. "You will first feel the baby move at about 8 weeks." - C. "A Doppler device can detect your baby's heart rate at 12 weeks." A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I can store my pumped milk in the door of the refrigerator." B. "I can use the microwave to thaw my frozen breast milk." C. "I will discard any unused breastmilk that is left in the bottle." D. "I can refreeze any breastmilk after it has been thawed." - C. "I will discard any unused breastmilk that is left in the bottle."
A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease - C. Giving the hepatitis B vaccine A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs. - B. "When my water broke, it was not clear." A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row." - D. "My baby may sometimes feed every hour for several hours in a row." A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. "I will use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hat on my baby's head prior to going outside." - D. "I will place a hat on my baby's head prior to going outside." A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching? A. "I should have less cramping while I'm breastfeeding." B. "I should breastfeed at least 8 to 12 times in a 24-hour period." C. "I should wait to breastfeed until my baby awakens from her nap."
A nurse is assessing a client who is at 20 weeks gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse give to the client? A. "Limit your intake of food to twice per day." B. "Decrease your intake of spicy foods." C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages. - B. "Decrease your intake of spicy foods." A nurse is providing education to a female client of child-bearing age. The nurse should state that which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle - D. Graafian follicle A nurse is performing a routine prenatal examination of a client who is in the second trimester. The client reports backaches with no other symptoms and refuses medication. Which of the following responses should the nurse make? A. "Try pelvic tilt exercises." B. "Limit your physical activity." C. "Soak in a warm bubble bath." D. "Lie flat on your back for 1 hour." - A. "Try pelvic tilt exercises." A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood? A. "I can have my partner apply counterpressure to my upper abdomen." B. "My baby will be monitored with a Doppler device during hydrotherapy." C. "I can have the nurse apply acupressure to my lower abdomen." D. "My TENS unit will not help with lower back pain during early labor." - B. "My baby will be monitored with a Doppler device during hydrotherapy." A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use? A. Large for gestational age B. Hypotonicity
C. Incessant crying D. Craniofacial anomalies - C. Incessant crying A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine - A. 480 mL urine output in 24 hr A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first? A. Complete blood count B. Liver enzymes C. Bilirubin level D. Urine ketones - D. Urine ketones A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconiumstained fluid. Which of the following actions should the nurse take? A. Gather equipment for neonatal resuscitation B. Discontinue oxytocin infusion C. Prepare for emergency cesarean delivery D. Position the parent to facilitate the McRoberts maneuver - A. Gather equipment for neonatal resuscitation A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take? A. Stop the oxytocin infusion B. Apply oxygen at 2 L/min via nasal cannula C. Administer methylergonovine intramuscularly D. Prepare for an emergent cesarean birth - A. Stop the oxytocin infusion A nurse is assessing an 18-hour-old newborn. Which of the following findings should be reported to the provider? A. Blood-tinged discharge from the vagina B. Overlapping sutures on the skull C. Subconjunctival hemorrhage
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? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks gestation - D. At 28 weeks gestation A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F) - B. Sponge bathe the newborn every other day A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation? A. Calcium B. Iron C. Vitamin D D. Vitamin C - D. Vitamin C A nurse is teaching a prenatal class for a group of antepartum clients. Which of the following pieces of information should the nurse include about the hepatitis B immunization? A. "The first dose should be administered at 3 months of age." B. "Your baby will receive this immunization subcutaneously, which means under the skin." C. "We will need your consent prior to administering the vaccine." D. "Your baby will receive this vaccine in a series of 5 doses." - C. "We will need your consent prior to administering the vaccine." A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt
D. Check the newborn's temperature twice daily - A. Place an opaque mask over the newborn's eyes A nurse is caring for a client who is at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. Which of the following actions should the nurse take? A. Slow the IV infusion rate B. Assist the client to a lateral position C. Assess the bladder for urinary retention D. Initiate an oxytocin infusion - B. Assist the client to a lateral position A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions." - A. "Call me so I can check your baby's latch the next time you breastfeed." A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? (Click on "Exhibit NCLEX 1" under Resources on the right-hand side for additional information about the client) A. Encourage the client to use a hot pack on the perineum B. Administer ferrous sulfate orally C. Help the client apply a breast binder D. Administer Rh immune globulin - B. Administer ferrous sulfate orally A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. Turn the client onto her left side B. Palpate the client's uterus C. Administer oxygen to the client D. Increase the client's IV fluids - A. Turn the client onto her left side A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first?
C. Measuring the time from the beginning of a contraction to the end of that same contraction D. Evaluating the time from the beginning of a contraction to the beginning of the next contraction - D. Evaluating the time from the beginning of a contraction to the beginning of the next contraction A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks gestation." D. "You should schedule a cesarean birth after your water breaks." - A. "You will have a cesarean birth prior to the onset of labor." A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Discontinue therapy if a fine rash appears B. Place moisturizing lotion on the newborn's skin C. Supplement feedings with 1 oz of glucose water every 4 hours D. Change the newborn's position every 2 to 3 hours - D. Change the newborn's position every 2 to 3 hours A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals." - A. "I will apply petroleum jelly to my baby's penis for the first few days." A nurse is assessing a female client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a heating pad to the mid-abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom - D. Ambulate the client to the bathroom
A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability - C. Impaired placental perfusion A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski - C. Rooting A nurse is providing counseling for a couple experiencing infertility issues. Which of the following statements by the nurse is appropriate? A. "Even though you can't have children biologically, you can always adopt a child." B. "You need to take a break from these attempts to conceive." C. "You might want to join our support group for couples who are experiencing similar problems." D. "Why didn't you get your immunizations when you were younger?" - C. "You might want to join our support group for couples who are experiencing similar problems." A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make? A. "You're eating for 2, so you should double your caloric intake." B. "You'll lose weight easily after the birth of your baby." C. "Plan to gain a total of 15 to 20 pounds during pregnancy." D. "Gaining weight will promote a healthy pregnancy. - D. "Gaining weight will promote a healthy pregnancy. A nurse is caring for a client who is pregnant. The client asks, "Is it okay to have a few beers while I'm pregnant?" Which of the following responses should the nurse make? A. "Total abstinence from alcohol is recommended." B. "One occasional beer during pregnancy is okay."
A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I didn't dilate past 6 centimeters." C. "The doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice." - D. "My baby has a higher risk of developing jaundice." A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan? A. "Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive." B. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." C. "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." D. "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative." - B. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? A. Platelet count 97,000/mm^ B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22 mg/dL - B. Deep tendon reflexes 4+ A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 seconds - B. Central cyanosis
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine - A. 480 mL urine output in 24 hr A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to brush your teeth gently." D. "Avoid taking acetaminophen while receiving this medication." - C. "Use a soft toothbrush to brush your teeth gently." A nurse is assisting with the care of a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis - B. Place the client in a left lateral position A nurse is caring for a client who is pregnant and whose last menstrual period (LMP) began on April 8. Using Naegele's rule, which of the following dates would be the client's estimated date of birth (EDB)? A. July 15 B. July 11 C. January 11 D. January 15 - D. January 15 A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure B. Assess the fetal heart rate pattern for 10 min prior to the procedure
A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour - C. Vaginal bleeding A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth - A. Gestational diabetes A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure during the collection of a blood sample from the baby." D. "You will feel some mild discomfort during the procedure." - D. "You will feel some mild discomfort during the procedure." A nurse is providing teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Boil bottles and nipples for 20 minutes after each use B. Mix 1 scoop of powdered formula with 2 oz of water C. Store prepared bottles in the refrigerator for up to 4 days D. Warm formula by heating bottles in the microwave on the lowest setting - B. Mix 1 scoop of powdered formula with 2 oz of water A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp - D. Check the integrity of the cord clamp A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are
giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is challenging when it's your baby, too." D. "You should speak to a therapist about these feelings." - B. "These feelings are common for expectant fathers in early pregnancy." A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take? A. Assess the fetal heart rate before and after the procedure B. Monitor the client's temperature every 4 hr after the procedure C. Medicate the client for pain 30 min prior to the procedure D. Perform cervical assessments every 2 hr after the procedure - A. Assess the fetal heart rate before and after the procedure A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in a prone position with arms and legs extended C. Rouse the infant every 1-2 hr to provide auditory and visual stimulation D. Provide kangaroo care for the infant - D. Provide kangaroo care for the infant A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent - B. Assess the newborn's blood glucose level A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? A. "This medication can cause your blood pressure to rise." B. "This medication can cause dry mouth."
A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? A. Assess fetal heart rate and contraction pattern every 15 min after insertion B. Thaw the frozen gel in a warm water bath prior to insertion C. Maintain the client in a side-lying position for 30 min after insertion D. Initiate an oxytocin infusion for induction 1 hr after gel insertion - C. Maintain the client in a side-lying position for 30 min after insertion A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL - A. Jaundice of the sclera A nurse is assessing a 4-hour-old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? A. Apply an oxygen hood over the newborn's head and neck B. Check the newborn's temperature using a temporal thermometer C. Place the naked newborn on the mother's bare chest and cover both with a blanket D. Give the newborn glucose water between feedings - C. Place the naked newborn on the mother's bare chest and cover both with a blanket A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? A. Painless, bright red bleeding B. Board-like uterus C. Persistent uterine contractions D. Abdominal pain - A. Painless, bright red bleeding A nurse is caring for a newborn who weighs 4 lb. How many kilograms does the newborn weigh? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.) - 1. A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the
nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection - C. Administer immune globulin to the client to prevent fetal isoimmunization A nurse is caring for a client who is receiving oxytocin to induce labor. Which of the following actions should the nurse take? A. Perform continuous fetal heart rate monitoring B. Measure maternal temperature every hour C. Evaluate the maternal contraction pattern every hour D. Check blood pressure every 5 min - A. Perform continuous fetal heart rate monitoring A nurse is providing teaching about weight gain during pregnancy for a client who is a primigravida of normal prepregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25 to 35 pounds during your pregnancy." B. "You should plan to gain 11 to 20 pounds during your pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight prior to pregnancy, you are encouraged to gain 28 to 40 pounds during pregnancy." - A. "You should plan to gain 25 to 35 pounds during your pregnancy." A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of fingers - A. Frequent headaches A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen
