ATI Maternal Newborn Proctored Exam 2024 Complete Solutions

ATI Maternal Newborn Proctored Exam 2024 s ATI MATERNAL NEWBORN PROCTORED EXAM 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. 2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? . Correct: Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress. 3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth? Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made. 4. Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge? Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well. Correct: In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied. 5. A client in preterm labor is admitted to the hospital. Which classification of drugs should the nurse anticipate administering? Correct: Tocolytics are used to stop labor. One of the most commonly used tocolytic drugs is ritodrine (Yutopar). 6. Which of the following are probable signs, strongly indicating pregnancy? Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a presumptive Sign of pregnancy. Incorrect: These are presumptive signs. They may indicate pregnancy or they may be caused by other conditions, such as disease processes. Correct: These are probable signs that strongly indicate pregnancy. Hegar’s sign is a softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color of the cervix as a result of the increased blood supply and increased estrogen. Ballottement occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the amniotic fluid and then falls downward. 7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action? Correct: Bladder distention can lead to postpartum hemorrhage. A full bladder displaces the uterus causing it not to contract properly. Emptying the bladder allows the uterus to contract more firmly. . 8. Which site is preferred for giving an IM injection to a newborn? Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. Powered by TCPDF (www.tcpdf.org) Correct: The middle third of the vastus lateralis is the preferred site for injections. 9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding? Correct: During pregnancy, the circulating blood volume increases by about 50%. In order to get rid of the excess fluid volume after delivery, the woman experiences an increased amount of urine output during the first few hours. 10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive? Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's blood sugar without harming the fetus. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? a.) Low birth weight b.) appropriate for gestational age c.) small for gestational age d.) large for gestational age --- Answer: b.) appropriate for gestational age A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborns mouth. This finding is a characteristic of which of the following conditions? a.) Mongolian spots b.) Milia spots c.) erythema toxicum d.) Epstein's pearls – -- Answer: d.) Epstein's pearls A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? a.) Hold the newborn vertically under arms and allow 1 foot to touch table b.) Stimulate the pads of the newborns hands with stroking or massage c.) Stimulate the soles of the newborns feet on the outer lateral surface of each foot d.) Hold the newborn in a semi-sitting position, then allow the newborns head and truck to fall backward --- Answer: d.) Hold the newborn in a semi-sitting position, then allow the newborns head and truck to fall backward