ATI Maternal Newborn
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1. A nurse is caring for a client who is in C. Calcium gluconate
preterm labor and is receiving magnesium
sulfate. The client begins to show indica- Explanation: The nurse
tions of magnesium sulfate toxicity. Which should discontinue the mag-
of the following medications should the nesium sulfate infusion imme-
nurse prepare to administer? diately and prepare to admin-
A. Protamine sulfate ister calcium gluconate IV to
B. Naloxone reverse the effects of magne-
C. Calcium gluconate sium to prevent cardiac and
D. Flumazenil respiratory arrest.
2. A nurse is caring for a client who is nul- C. Offer the client hydrothera-
liparous and experiencing hypertonic uter- py
ine dysfunction. An assessment indicates 3
cm dilation. Which of the following actionsExplanation: Therapeutic rest
should the nurse take? measures should be initiated
for a client who has hyperton-
A. Encourage the client to bear down with ic uterine dysfunction. Ther-
contractions apeutic rest can include hy-
B. Request a prescription to initiate oxy- drotherapy and analgesia to
tocin relieve pain. Decreasing uter-
C. Offer the client hydrotherapy ine contractions and helping
D. Assist the client with ambulation the client relax and sleep will
help prevent early exhaus-
tion.
3. A nurse is evaluating a client who has just D. "I should avoid waiting too
received instructions about breastfeeding. long between feedings."
Which of the following statements should
the nurse identify as an indication that the Explanation: Mastitis is an in-
client understands how to prevent masti- flammation or infection of the
tis? breast. Risk factors include
insufficient emptying of the
A. "I will wear an underwire bra to provide breasts during breastfeeding,
support when my milk comes in." stress, illness, poor nutrition,
B. "I will apply petroleum jelly if my nipples and fatique.
become cracked."
C. "I will apply warm compresses to my
breast twice a day."
, ATI Maternal Newborn
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D. "I should avoid waiting too long between
feedings."
4. A nurse is assessing a client who has hy- D. Presence of ketones in the
peremesis gravidarum. Which of the follow- urine
ing findings should the nurse expect?
Explanation: the nurse should
A. Elevated serum potassium level expect a client who has
B. Rapid weight gain hyperemesis gravidarum to
C. Peripheral edema have ketonuria due to an in-
D. Presence of ketones in the urine adequate dietary intake, re-
sulting in the breakdown of
protein and stored fat.
5. A community health nurse is planning care B. A 4-day-old newborn who
for a 4 high-risk newborns who were dis- has an elevated bilirubin level
charged yesterday. Which of the following and requires phototherapy.
newborns should the nurse plan to care for
first? Explanation: The nurse
should use Maslow's Hierar-
A. A 1-week-old newborn who needs anoth- chy of Needs, the ABC prior-
er phenylketonuria screening test ity-setting framework, and/or
B. A 4-day-old newborn who has an elevated nursing knowledge to identify
bilirubin level and requires phototherapy which risk poses the greatest
C. A 10-day-old newborn who is small for threat to the client. An elevat-
gestational age and requires daily weigh- ed bilirubin level can lead to
ing. kernicterus: therefore: it is im-
D. A 2-week-old newborn who was born at perative for the nurse to initi-
35 weeks gestation and weighed 2, 268 g ate phototherapy immediately
to help prevent this danger-
ous outcome.
6. A nurse is caring for a client at 12 weeks A. "You should plan to gain no
gestation who has a BMI of 45. Which of more than 20 pounds during
the following pieces of information should your pregnancy."
the nurse provide for the client regarding
the recommended weight gain during her Explanation: Women who
pregnancy? have a BMI above 30 should
limit their weight gain to 11
, ATI Maternal Newborn
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A. "You should plan to gain no more than 20 to 20 pounds during preg-
pounds during your pregnancy." nancy. Excessive wight and
B. "You should plan to gain between 25 and weight gain increase the risk
35 pounds during your pregnancy." of complications during and
C. "You should not plan to gain any weight after pregnancy.
during your pregnancy because you are al-
ready well-nourished."
D. "Since you hav
7. A nurse is caring for a client who has clin- D. Pelvic inflammatory dis-
ical manifestations of ectopic pregnancy. ease (PID)
Which of the following findings is a risk
factor for an ectopic pregnancy? Explanation: An ectopic preg-
nancy occurs when the fer-
A. Anemia tilized egg implants in tissue
B. Frequent urinary tract infections outside of the uterus and pla-
C. Previous cesarean birth centa, and the fetus begin to
D. Pelvic inflammatory disease (PID) develop in this area. The most
common site is within a fal-
lopian tube, but ectopic preg-
nancies can occur in the oc-
cur in the ovary or the ab-
domen. Most cases are a re-
sult of scarring caused by
a previous tubal infection or
tubal surgery. Therefore, PID
places the client at risk of an
ectopic pregnancy.
8. A nurse is caring for a clint who states, "I C. Fetal heart tones auscultat-
think I am pregnant." Which of the following ed by Doppler
findings should the nurse identify as a pos-
itive sign of pregnancy? Explanation: fetal heart tones
heard by doppler are a pos-
A. Positive serum pregnancy test itive sign of pregnancy. The
B. Amenorrhea only explanation for hearing
C. Fetal heart tones auscultate by Doppler fetal heart tones is the pres-
D. Chadwick sign ence of a fetus.
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