ATI PN MATERNAL NEWBORN PROCTORED EXAM

ATI PN MATERNAL NEWBORN PROCTORED EXAM

VERSION 18

• A nurse is caring for a client who has uterine atony and is

experiencing postpartum hemorrhage. Which of the following actions is the nurse’s priority?• Massage the client’s fundus Uterine atony and postpartum hmorrhage indicate that thisclient is at the greatest risk for hypovolemic shock. This can compromise the client’s vital organs, which can lead todeath. Therefore, the nurse’s priority is to massage the client’s fundus to minimize blood loss.

• A nurse is caring for a client who is to receive oxytocin to

augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and shouldbe reported to the provider?• Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for theadministration of oxytocin and should be reported to theprovider.

• A nurse is assessing a client who has severe preeclampsia. Which

of the following manifestations should the nurse expect?• Blurred vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visualdisturbances, such as blurred vision, double vision, or dark spots in the visual field.

• A nurse is assessing a client who is 1 day-postpartum and has a

vaginal hematoma. Which of the following manifestation shouldthe nurse expect?• Vaginal pressure • The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.

• A nurse is caring for a client who is at 36 weeks of gestation and

has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? 1 / 2

• Biophysical profile • A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.

• A nurse is providing teaching for a client who has a new

prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effectof this medication?• Depression • The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives.Other common adverse effects of the medication includeamenorrhea, weight gain, headache, nausea, breatkthrough bleeding, and breast tenderness.

• A nurse is caring for a postpartum client who is receiving heparin

via a continuous IV infusion for thrombophlebitis in her left calf.Which of the following actions should the nurse take?• Maintain the client on bed rest • The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary emoblism. Elevation of the affected leg is recommended.

• A nurse is providing teaching to a client who is at 40 weeks of

gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?• “I can administer oxytocin 4 hours after the insertion of the medication.” • The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.

• A nurse is assessing four newborns. Which of the following

findings should the nurse report to the provider?• A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F).• An axillary temperature greater than 37.5 degrees (99.5 degrees F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.

• A nurse is caring for a client who is at 30 weeks of

gestation and has a prescription for magnesium sulfate IV to

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