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.
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ATI Maternal Newborn Proctored Exam 2019 (Real Exam)
The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient’s baseline of normal function.
c. Educate the patient and family about the procedure.
d. Gather appropriate equipment for the patient’s needs.
ANS: B
The goal of the preoperative assessment is to identify a patient’s normal preoperative function and the presence of any risks to recognize, prevent, and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the priority reason/goal for completing an assessment of the surgical patient.
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and thus increase the risk of hemorrhaging. Discontinue at least 48 hours before surgery. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Prednisone is a corticosteroid, and dosages are often temporarily increased rather than held.
The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse take when consulting with the health care provider?
a. Ask for a radiological examination of the chest.
b. Ask for an international normalized ratio (INR).
c. Ask for a blood urea nitrogen (BUN).
d. Ask for a serum sodium (Na).
ANS: B
INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the blood. Anticoagulants can be utilized for different conditions, but its action is to increase the time it takes for the blood to clot. This action can put the surgical patient at risk for bleeding tendencies.
Typically, if at all possible, this medication is held several days before a surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are diagnostic screening tools for surgery but are not specific to anticoagulants.
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve?
a. Manage pain
b. Prevent atelectasis
c. Reduce healing time
d. Decrease thrombus formation
ANS: B
After surgery, patients may have reduced lung volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk. During general anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages. Diaphragmatic breathing does not manage pain; in some cases, if splinting and pain medications are not given, it can cause pain. Diaphragmatic breathing does not reduce healing time or decrease thrombus formation. Better, more effective interventions are available for these situations.
The nurse is caring for a postoperative patient on the medical-surgical floor. Which activity will the nurse encourage to prevent venous stasis and the formation of thrombus?
a. Diaphragmatic breathing
b. Incentive spirometry
c. Leg exercises
d. Coughing
ANS: C
After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; thesepromote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis and pneumonia.
The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse’s best next step?
a. Encourage the patient to practice at a later date.
b. Assess for the presence of anxiety, pain, or fatigue.
c. Ask the patient why exercises are not being done.
d. Evaluate the educational methods used to educate the patient.
ANS: B
If the patient is unable to perform leg exercises, the nurse should look for circumstances that may be impacting the patient’s ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Evaluation of educational methods may be needed, but in this case, principles and demonstrations are being utilized. Asking anyone “why” can cause defensiveness and may not help in attaining the answer. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals.
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Exam
1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a bright red, topinkish brown, to creamy white.
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the bed
Lochia should last for about 3 weeks, changing color every few days
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?
Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord compression. Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
Correct: Late decelerations are associated with uteroplacental insufficiency and are a signof fetal hypoxia. Repeated late decelerations indicate fetal distress. The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head Maternal contractions are not adequate enough to deliver the fetusThe fetus is not receiving adequate oxygen and is in distress
3 . Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of theclient and the family will be high. Inserting an indwelling catheter helps to keep thebladder empty and free from injury when the incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
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.
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Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well.
Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms.
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.
Incorrect: Using soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing. The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
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).
Incorrect: Anticonvulsants are used for clients with pregnancy-induced hypertension who are likely to seize.
Incorrect: The glucocorticoids (e.g., betamethasone and dexamethasone) are used for accelerating fetal lung maturation and production of surfactant. They are commonly used if the membranes are ruptured or labor cannot be stopped.
Incorrect: Anti-infective are used if there is infection. Preterm labor may or may not involve ruptured membranes with its accompanying risk of infection.
Tocolytics Anticonvulsants Glucocorticoids Anti-infective
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.
Incorrect: These are presumptive signs that might indicate pregnancy, but they might be caused by other conditions, such as disease processes.
Presence of fetal heart sounds and quickening Missed menstrual periods, nausea, and vomiting Hegar's sign, Chadwick's sign, and ballottement Increased urination and tenderness of the breasts
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.
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be displaced and increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This, however, does not relate to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or not. A full bladder displaces the uterus causing it not to contract properly, which may lead to postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing dehiscence. Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
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.
Correct: The middle third of the vastuslateralis is the preferred site for injections.
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.
Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus maximus) due to decreased muscle mass.
Ventrogluteal Vastuslateralis Rectus femoris Dorsogluteal
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?
Incorrect: Urinary tract infections are common during pregnancy and in the postpartum period. Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of a UTI.
Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There has been no damage to the kidneys. Incorrect: Most women do receive some IV fluids during labor and delivery, however the IV rates are carefully calculated according to weight.
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.
Urinary tract infection
High output renal failure
Excessive use of IV fluids during delivery
Normal diuresis after delivery
10.If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive?
Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can cause damage to the fetus. They are not used in gestational diabetes for that reason.
Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe hypoglycemia. Clients with gestational diabetes have hyperglycemia.
Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's blood sugar without harming the fetus.
Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta and can cause damage to the fetus. They are not used for gestational diabetes for that reason.
Metformin (Glucophage) Glucagon
Insulin
Glyburide (DiaBeta)
0
2007