ATI Maternal Retake - Proctored. Level 3.

1) Which of the following assessment findings in an infant should indicate to a nurse that
suctioning of the nasopharynx is needed?
A) The infant is beginning to cough
B) The newborns pulse oximetry is 91
C) The infant's respiratory rate is 32/min.
D) The infant's respiratory rate is irregular
2) A nurse is providing teaching to a postpartum client who has type 1 diabetes and is
breastfeeding her newborn. Which
of the following instructions should the nurse give to the client?
A) Take more insulin with each meal that you did prior to pre pregnancy
B) Maintain scheduled mealtimes for yourself
C) Check your blood glucose levels every 8 hours
D) Limit your carbohydrate intake to 30 grams per day
3) A nurse is assessing the reflexes of a term newborn. After placing the newborn in a supine
position, which of the
following would the nurse use to elicit the Moro reflex
A) Turn the newborn’s head to one side
B) Make a loud noise above the newborn
C) Tap the newborns forehead with a finger
D) Touch the newborns cheek with a finger
4) A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp.
Which of the following
actions should the nurse include in the plan?
A) Give the newborn 1 oz of glucose water every 4 hours
B) Apply a thin layer of lotion to the newborns skin every 8 hours
C) Dress the newborn in a thin layer of clothing during the therapy
D) Ensure the newborns eyes are closed beneath the shield
5) A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the
following clients should the nurse asses first?
A) A client who has hyperemesis gravidarum and a sodium level of 110
B) A client who has preeclampsia and a creatine level of 1.1
C) A client who has diabetes mellitus and an HbA1c of 5.8
D) A client who has placenta previa a hematocrit of 36
6) A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has
diabetes. The test reveals no
accelerations of the fetal heart rate for 20 minutes. Which of the following actions should the
nurse take?
A) Perform vibroacoustic stimulation
B) Collect a specimen for an indirect Coomb’s test
C) Conduct a vaginal exam
D) Place the client in the Trendelenburg position
7) A nurse is preparing to administer gentamycin 2 mg/kg IM to a client who has a pelvic
inflammatory disease and weighs 132 lb. Available is gentamycin injection at 40mg/ml. How
many ml should the nurse administer?
3 mL
8) A nurse is caring for a client who is 1-day post-partum and breastfeeding her newborn. The
client reports sore nipples.
Which of the following actions should the nurse take?
A) Have the client limit the length of breastfeeding to 5 minutes per breast
B) Assess the newborns latch while breastfeeding
C) Offer supplemental formula between the newborn’s feedings
D) Instruct the client to wait 4 hours between daytime feedings
9) A nurse is admitting a client who is in active labor and has had two prior cesarean births. The
nurse should identify
that the client is at an increased risk for which of the following complications?
A) Uterine rupture
B) Precipitous labor
C) Failure to progress
D) Abruptio placentae
10) A nurse is caring for a 2-day-old newborn who was born at 35 weeks gestation. Which of the
following actions should the nurse take?
A) Measure the abdominal circumference at the level of the newborn’s umbilicus every 12 hours
B) Provide the newborn with an iron-rich formula containing vitamin b12 every 12 hours
C) Administer nitric oxide inhalation therapy to the newborn
D) Insert an orogastric decompression tube with low suction
11) A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The
client expresses concerns
about preparing her 2-year-old for a new sibling.
A) Move your toddler to his new bed 2 months before the baby comes home
B) Avoid bringing your toddler to prenatal visits
C) Require scheduled interactions between the toddler and the baby
D) Let your toddler see you carry the baby into the home for the first time
12) A nurse manager in a newborn nursery is reviewing infection control procedures with a
group of newly hired nurses.
Which of the following instructions should the nurse manager include in the teaching?
A) Place newborn bassinets at least 3 feet apart
B) Maintain airborne precautions
C) Allow parents to enter the nursery if wearing a mask
D) Place the newborns foot on a sterile field during a heel stick
13) A nurse is caring for a client who is in active labor and reports sudden, severe lower
abdominal pain. The nurse observes a drop in the client’s blood pressure and notes cool skin and
pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following
complications should the nurse expect?
A) Placenta Previa
B) Amniotic fluid embolism
C) Uterine rupture
D) Umbilical cord prolapse
14) A nurse is reviewing the medical record for a client who is receiving treatment for
gestational diabetes. Which of the following medications should the nurse expect to administer?
A) Nifedipine
B) Chlorpromazine
C) Glyburide
D) Levothyroxine
15) 1) assess the newborn for reflex bradycardia 2) compress the bulb syringe 3) place bulb in
mouth 4) use the bulb
syringe to suction nose
16) A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the
following findings should the
nurse report to the provider?
A) Urine protein of 3+
B) Deep tendon reflexes of 2+
C) Hemoglobin 13
D) Blood glucose 110
17) A nurse is admitting a client who is at 38 weeks gestation following spontaneous rupture of
membranes. The nurse
performs a vaginal examination and palpates the umbilical cord. Which of the following actions
should the nurse take
first?
A) Request that the provider insert an intrauterine pressure catheter
B) Initiate oxytocin via continuous IV infusion
C) Place the client in a left lateral position
D) Exert continuous upward pressure on the presenting parts
18) A nurse is caring for a client who is in labor. Which of the following findings should prompt
the nurse to reassess the
client?
A) An urge to have a bowel movement during contractions
B) Progressive sacral discomfort during contractions
C) A sense of excitement and warm, flushed skin
D) Intense contractions lasting 45 to 60 seconds
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27) A nurse is assessing a client who is requesting a combined oral contraceptive. Which of the
following findings should
indicate to the nurse that the client has a contraindication?
A) The client is breastfeeding her 4-week-old newborn
B) The client is 25 years old
C) The client weighs 115 kg
D) The client drinks 240 ml of wine a day
28) A nurse is admitting a client to the birthing unit who reports contractions started 1 hour ago.
The nurse determines
the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which
of the following
conditions?
A) Postpartum hemorrhage
B) Incompetent cervix
C) Ectopic pregnancy
D) Hyperemesis gravidarum
29) A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following
findings should the nurse
expect?
A) Increased muscle tone
B) Jitteriness
C) Petechiae
D) Abdominal distension
30) Image of prolonged decelerations
31) A nurse is caring for a client who has bladder distension following a vaginal birth. Which of
the following actions
should the nurse take first?
A) Insert a urinary catheter
B) Pour warm water over the client’s perineum
C) Assist the client to the bathroom
D) Offer the client a sitz bath
32) A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks gestation.
The nurse should report
which of the following findings to the provider as an indication of an imminent spontaneous
abortion?
A) Elevated hCG
B) Scant, bright red spotting
C) Cervical dilation
D) Slight abdominal cramps
33) A nurse manager on the labor and deliver unit is teaching a group of newly licensed nurses
about maternal
cytomegalovirus. Information included in teaching?
A) Mothers will receive prophylactic treatment with acyclovir prior to delivery
B) Lesions are visible on the mother genitalia
C) Transmission can occur via the saliva and urine of the newborn
D) The infection requires that airborne precautions be initiated
34) A nurse is providing teaching about increasing dietary fiber to an antepartum client who
reports constipation.
Highest in fiber content?
A) Cabbage
B) Oatmeal
C) Asparagus
D) Lentils
35) A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
Which of the following
instructions should the nurse include?
A) Expect two to four wet diapers every 24 hours
B) Offer the newborn 30 ml of water between feedings
C) Feed the newborn 5 to 10 minutes per breast
D) Allow the baby to feed at east every 3 hours
36) A nurse is assessing a full-term newborn upon admission to the nursery Which of the
following clinical findings
should the nurse report to the provider.
A) Subconjunctival hemorrhage
B) Rust stained urine
C) Single palmar creases
D) Transient circumoral cyanosis
37) A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the
following clinical findings
should the nurse expect?
A) Temperature 37.4/99.3
B) Uterine tenderness
C) Scant lochia
D) WBC 9,000
38) A nurse on the labor and delivery unit is planning care for a client who has human
immunodeficiency virus. Which of
the following is an appropriate action for the nurse to take following the birth of the newborn?
A) Initiate contact precautions for the newborn
B) Administer IV antibiotics for the newborn
C) Encourage the mother to breastfeed the newborn
D) Cleanse the newborn immediately after delivery
39) A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old
male newborn at home.
Which of the following statements should the nurse make to the client?
A) Notify your baby’s pediatrician if he urinates less than six times a day
B) Swaddle your baby tightly with his legs extended before laying him down to sleep
C) Place triple antibiotic ointment on your baby’s umbilical cord twice per day
D) Retract the foreskin to clean your baby’s penis during each bath
40) A nurse is reviewing the laboratory report for a client who is in active labor. The client tested
positive for group B
strep. Which of the following medications should the nurse plan to administer to the client?
A) Ampicillin
B) Cefotetan
C) Doxycycline
D) Fluconazole
41) A nurse on an antepartum unit is receiving change of shift report for four clients. Which of
the following should the
nurse assess first?
A) A client who is at 38 weeks gestation and is experiencing painful urination
B) A client who is at 12 weeks gestation and is experiencing nausea and vomiting
C) A client who is at 34 weeks gestation and is experiencing epigastric pain and headache
D) A client who is at 39 weeks gestation and is experiencing cramping and spotting
42) A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of
the following actions
should the nurse include in the plan of care?
A) Dress the newborn in lightweight clothing
B) Measure the newborns temperature every 8 hours
C) Avoid using lotion or ointment on the newborns skin
D) Keep the newborn supine throughout the treatment
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D) I can still have a hot dog at the ballpark
52) A nurse is caring for a client who has developed eclampsia. Which of the following actions
should the nurse
implement after the client experiences a convulsion?
A) Place the client in a Trendelenburg position
B) Assist the client to void
C) Administer oxygen to the client via face mask
D) Give calcium gluconate to the client
53) A nurse is caring for newborn who is 1 hour old and has a respiratory rate of 50/min, a heart
rate of 130/minute, and
an axillary temperature of 36.1 (97). Which of the following actions should the nurse take?
A) Apply a cap to the newborns head
B) Obtain an oxygen saturation level
C) Reposition the newborn
D) Give the newborn a warm bath
54) A nurse is caring for a client who is at 30 weeks of gestations and receiving magnesium
sulfate for preeclampsia. The
nurse should recognize which of the following manifestations as an adverse reaction to the
medication?
A) Hyperglycemia
B) Urine output 20 mL/hour
C) Hypertension
D) Respiratory rate 16/min
55) A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy.
Which of the following
manifestations should the nurse expect?
A) Sharp pelvic pain
B) Bright red vaginal discharge
C) Elevated blood pressure
D) Scaphoid abdomen
56) A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late
decelerations. Which of
the following actions should the nurse take?
A) Place the client in a lateral position
B) Decrease maintenance IV solution infusion rate
C) Administer misoprostol 25 mcg vaginally
D) Administer oxygen via face mask
57) A nurse is planning care immediately following birth for a newborn who has a
myelomeningocele that is leaking
cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
A) Monitor the rectal temperature every 4 hours
B) Cleanse the site with povidone-iodine
C) Administer broad spectrum antibiotics
D) Prepare for surgical closure after 72 hours
58) A nurse is providing teaching to a client about postpartum care. Which of the following
information should the nurse
include?
A) Breasts will be firm and tender 3 to 5 days after delivery
B) Bleeding will remain bright red for the next 6 to 8 weeks
C) You don’t need to use birth control if you are exclusively breastfeeding
D) You should begin performing Kegel exercises 6 to 7 weeks after delivery
59) A nurse is caring for a client who has pregestational diabetes. Which of the following
findings should indicate to the
nurse the client has hyperglycemia?
A) Dizziness
B) Increased urination
C) Sweating
D) Double vision
60) A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following
statements indicate an
understanding of the teaching?
A) The nurse should wait for the first Apgar score before initiating resuscitation efforts
B) The nurse should identify that the newborn is in severe distress with an Apgar score of 8
C) The nurse should measure the newborns muscle tone when assigning an Apgar score
D) The nurse should determine the Apgar score at 2 and 7 minutes after birth
61) A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate.
Which of the following clinical
findings should the nurse instruct the client to report?
A) Increased respiratory rate
B) Increased fetal movement
C) Increased muscle weakness
D) Increased urine output
62) A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the
following actions should the
nurse take?
A) Maintain eye contact during feedings
B) Plan care to minimize handling the newborn
C) Schedule larger volume feedings at less frequent intervals
D) Swaddle the newborn with his legs extended
63) A nurse is caring for a client who is in active labor and is receiving oxytocin via continuous
IV infusion. The nurse has
applied an internal fetal heart monitor and recognizes an early deceleration. Which of the
following actions should the
nurse take?
A) Assist the client to lay on her right side
B) Discontinue the oxytocin
C) Continue to monitor the client
D) Administer oxygen at 8 l/minute per mask
64) A nurse is caring for a client who is experiencing uterine atony immediately following
delivery. The client fails to
respond to oxytocin. The nurse should anticipate the use of which of the following medications?
A) Hydralazine
B) Methylergonovine
C) Terbutaline
D) Betamethasone
65) A nurse is developing an educational program about hemolytic disease in newborns. Which
genetic information
should be included in the program?
A) The mother and father are both rh positive
B) The mother is rh negative and the father is rh positive
C) The mother and father are rh negative
D) The mother is rh positive and the father is rh negative
66) The nurse is assessing a newborn who is 4 hours old. Which of the following findings should
the nurse identify as the
priority to report to the provider?
A) Overlapping of the cranial bones
B) Small, distended white sebaceous glands on the face
C) Forward and lateral positioning of the ears
D) Bluish discoloration of the hands and feet
67) A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks gestation
and requests an
amniocentesis to determine the sex of the baby. How should the nurse respond?
A) We can schedule the procedure for later today if you would like
B) This procedure determines if your baby has genetic or congenital disorders
C) Your provider will schedule a chorionic villus sampling
D) You cannot have an amniocentesis until you are 35 years old
68) A nurse is providing prenatal teaching to a client who is vegan and is trying to increase
intake of B12. Which foods
should recommend?
A) Fortified soy milk
B) Brown rice