ATI RN Maternal Newborn Proctored 2019 Retake 1 - Study Guide

ATI RN Maternal Newborn Proctored 2019 Retake 1

1. A nurse is assessing a client following an amniocentesis. Which of the following findings should

the nurse recognize as a complication? (Select all that apply.)

A. Leakage of amniotic fluid

B. Urinary tract infection

C. Preterm labor

D. Amnionitis

E. Polyhydramnios

Rationale: MN RM 10.0 Ch.6 p.34; Complications: amniotic fluid emboli, maternal or fetal hemorrhage,

fetomaternal hemorrhage with Rh isoimmunization, maternal or fetal infection, inadvertent fetal damage

or anomalies involving limbs, fetal death, inadvertent maternal intestinal or bladder damage, miscarriage

or preterm labor, premature rupture of membranes, and leakage of amniotic fluid.

2. A nurse is providing prenatal teaching to a client about increasing her dietary intake of zinc. Which

of the following foods has the highest zinc content?

A. 1 cup of oranges (100 mcg/1 cup)

B. 1 cup of broccoli (400 mcg/1 cup)

C. 1 cup of cantaloupe (300 mcg/1 cup)

D. 1 cup of peanuts (4.8 mg/1 cup)

Rationale: http://nutritiondata.self.com/

3. A client and her partner ask the nurse for information about permanent contraception. Which of the

following statements should the nurse include in the counseling?

a. “The menstrual cycle is shorter after a tubal ligation.” (No mention)

b. “A man is usually sterile after a vasectomy.” (The man will be considered sterile after 20

ejaculations, or a week to several months)

c. “Most sterilization procedures are considered irreversible.” (Both types of male/female

sterilization are reversible, but are either irreversible in the case of conception or not successful)

d. “A woman should use contraception for 1 to 2 months after a tubal ligation.” (Every possible time;

no protection against STDs)

Rationale: MN RM 10.0 Ch.1 p.8

4. A nurse is caring for a newborn who was delivered 12 hr ago. The mother has gestational diabetes.

Which of the following assessment findings should indicate to the nurse that the newborn is experiencing

hypoglycemia? (Select all that apply.)

a. Abdominal distention

b. Difficulty feeding

c. Blood glucose 60 mg/dL

d. Jitteriness

e. Sweating

Rationale: MN RM 10.0 Ch.24 p.166; Jitteriness; twitching; a weak, high-pitched cry; irregular

respiratory effort; cyanosis; lethargy; eye rolling; seizures; and a blood glucose level less than 40 mg/dL

by heel stick.

5. A nurse is assessing a client and observes the umbilical cord protruding from the vagina. Aftercalling

for assistance, which of the following is the nurse’s priority intervention?

a. Place a rolled towel under the client’s right hip.

b. Wrap the cord with a sterile towel saturated in normal saline.

c. Apply upward pressure against the presenting part.

Administer oxygen via nonrebreather face mask.

d. Rationale: p107 maternal newborn ati.

● Call for assistance immediately.

●● Notify the provider.

●● Use a sterile-gloved hand, insert two fingers into the

vagina, and apply finger pressure on either side of the

cord to the fetal presenting part to elevate it off of

the cord.

●● Reposition the client in a knee-chest, Trendelenburg, or a

side-lying position with a rolled towel under the client’s

right or left hip to relieve pressure on the cord.

●● Apply a warm, sterile, saline-soaked towel to the visible

cord to prevent drying and to maintain blood flow.

●● Provide continuous electronic monitoring of FHR for

variable decelerations, which indicate fetal asphyxia

and hypoxia.

●● Administer oxygen at 8 to 10 L/min via a face mask to

improve fetal oxygenation.

●● Initiate IV access, and administer IV fluid bolus.

●● Prepare for an immediate vaginal birth if cervix is fully

dilated or cesarean section if it is not.

●● Inform and educate the client and her partner about

the interventions.

6. A nurse is teaching a client who is postpartum about self-care measures following a median

episiotomy. Which of the following statements by the client indicates an understanding of the teaching?

a. “I will cleanse myself after each bowel movement by wiping in a circular motion with a moist

cloth.”- front to back (urethra to anus)

b. “I will apply an ice pack to the stitched area to relieve pain.”- non-pharmacological pain

management.

c. “I will use a peri-bottle filled with cold water to rinse my vaginal area after I urinate.”- warm not

cold

d. “I will expect an increase in swelling as the stitched area heals.”- worsening

P. 119 ati maternal newborn.

7. A nurse is assessing a newborn whose mother has a cocaine use disorder. Which of the following

newborn findings should the nurse expect?

a. Hypotension

b. Increased startle reflex

c. Increased head circumference

d. Increased cardiac output

Rationale. P 183 maternal newborn. Neonatal substance withdrawal

● CNS: High-pitched, shrill cry; incessant crying;

irritability; tremors; hyperactivity with an increased

Moro reflex; increased deep-tendon reflexes; increased

muscle tone; disturbed sleep pattern; hypertonicity;

convulsions

8. A client is in preterm labor and is receiving magnesium sulfate. The client begins to show signs of

magnesium sulfate toxicity. Which of the following should the nurse anticipate administering?

a. Calcium gluconate

b. Regular insulin

c. Protamine sulfate

d. Naloxone

Rationale: p61 ati maternal newborn