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lOMoARcPSD|16248954ATI detailed answers ATI detailed answers
Maternal-Child Nursing (Chamberlain University)
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1) 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
i. 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.
2) A nurse in the newborn nursery is caring for a group of newborns. Which of the
following newborns requires immediate intervention?
a. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F)
Rationale: Hyperthermia in the newborn requires immediately intervention.
Hyperthermia is typically caused by increased heat production related to sepsis
or decreased heat loss
3) 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.
b. 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.
4) A nurse is caring for a
newborn immediately
following birth. After
assuring a patent airway,
what is the priority
5) nursing action?
6) A nurse is caring for a
newborn immediately
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following birth. After
assuring a patent airway,
what is the priority
7) nursing action?
4. A nurse is caring for a newborn immediately following birth. After assuring a patent
airway, what is the priority nursing action?
a. Dry the skin.
b. Rationale: The newborn should be thoroughly dried, covered with a warm
blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s
head to prevent cold stress. The newborn responds to the cooler environment
by increasing his respiratory rate, which can lead to respiratory distress. Based on
Maslow’s hierarchy of needs, this is the most important nursing action after
securing the airway.
5. 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 occurs during the first trimester and near the end of the pregnancy.”
b. 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
6. 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?
a. 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.
7. 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. Clear the respiratory tract.
b. Rationale: Clearing the airway of the infant is the first action the nurse should
take immediately following delivery.
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8. A nurse in a family planning clinic is caring for a 17-year-old female client who is
requesting oral contraceptives. The client states that she is nervous because she has
never had a pelvic examination. Which of the following responses should the nurse
make?
a. "What part of the exam makes you most nervous?
b. "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
9. 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 arteries and one vein
b. 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.
10. 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. An intrauterine device (IUD)
b. Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which
makes it one of the most reliable methods of contraception.
11. A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery,
the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of
extremities; grimace in response to suctioning of the nares; body pink in color with blue
extremities. Calculate the newborn’s Apgar score.
a. 6 points
b. Correct Rationale: The Apgar score is 6 out of a possible 10. It is based on 5 signs
evaluated at 1 and 5 min after delivery that indicate the physiologic state of the
newborn as he transitions from intrauterine life to extrauterine life: heart rate
over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in
response to suctioning of the nares = 1; body pink in color with blue extremities
= 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the
womb.
12. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which
of the following findings should the nurse expect?
a. Fundus firm, at the level of the umbilicus
b. Rationale: Within 12 hours after birth, the fundal tone is expected to be firm, and
the location is typically palpated midline and at the level of the umbilicus.
13. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and
displaced to the right. Based on these findings, which of the following actions should the
nurse take?
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