ATI PN MATERNITY PROCTORED EXAM

ATI PN MATERNITY PROCTORED EXAM

VERSION 34

• A primigravida mother who is one day post delivery tells the nurse that she is not producing enough

milk for her new baby, and she wants to begin breastfeeding at home when her milk comes in. What info should the nurse obtain before responding to the client?

AͲwhen the lactation consultant is scheduled to visit the client in her home

BͲthe womans understanding of how her body produces breast milk.

CͲif the woman is feeling pressured by her family to breast feed her infant.

DͲwhy the woman thinks her infant is not receiving enough milk

CorrectͲ D

Sometimes new mothers do not understand that colostrums provided adequate nutrition the first three days following delivery. So the clients thinking regarding this issue should be assessed (D). Waiting for a visit from a lactation consultant (A) to address this issue is likely to inhibit lactation if the mother delays suckling the infant. Although assessing the mother’s understanding of milk production (B) may provide a teaching opportunity, it does not elicit information about the clients concern regarding the delay of breast feeding/ Assessing the mothers feelings about her family’s desire for her to breastfreed (C) doesn’t address the issue athand.

• A client with endometritis is preparing for discharge on her third postpartum day, Which statement by

he client indicates that the discharge teaching was effective?

AͲI should limit my visitors until this infection clears

BͲI will resume breastfeeding when the infection is gone

CͲI should sit an upright position as much as possible

DͲI will stop taking antibiotics when my fever disappears

Correct Ͳ C

A client with endo metris should sit in an upright position© to facilitate drainage of lochia and prevent infected fluids from enetering the peritoneal cavity. (A,B and D) indicate a needs for additional instruction. Endometritis is an infection of the endometrial lining and is not contagious, so visitors do not need to be restricted or limited(A). there is no indication to stop or withholding breastfeeding (b) if a client develops endometritis. All antibiotics should be completed regardless of fever abatement.

• A multipara postpartum client complains about intenst cramping while breastfeeding. What

instructions should the nurse provide to this client? 1 / 3

AͲ TAKE A PRESCRIBED ANALGESIC AN HOUR PRIOR TO BREASTFEEDING

BͲ change then infants position during the next feeding CͲ drink two glasses of Water 30 minutes prior to breastfeeding DͲ void and completely empty bladder before each feeding

CorrectͲ a

The client is experiencing atterpains which typically affect multigravidas due to relaxation of the uterine muscles and release of oxytocin during breastfeeding. The client should take a prescribed analgesic one hour before breastfeeding (A) to relieve this discomfort. Infant positioning during B is effective in relieving sore nipples. C and D are not effectivemeasures for relieving uttering cramping.

• A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a motor

vehicle collossion. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor?

AͲ Suspect that the monitor is malfunctioning and recount the heart rate manually

BͲExplain to the client that a rapid heart right is normal for a preterm fetus.

CͲPerform a vaginal Examination to see if the accident initiated preterm labor

DͲAdminister oxygen to the client and contact the healthcare provider immediately.

CorrectͲ D

Administering oxygen and contacting the healthcare provider (D) are the priority interventions for fetal oxygen deprivation secondary to placental abruption, which is known complication of trauma to the mother. AͲ wastes time and increased the chance of errors in the assessment. BͲprovides the client with dales information. CͲ increased the risk of hemorrhage, further compromising fetal oxygenation, and is not a recommended intervention at this time. Vaginal bleeding should be assessed without palpation.

• in caring for a newborn infant who starts gagging and becomes cyanotic, what action should the nurse

implement first?

aͲgive three back blows to clear the airway

bͲcall for assistance and start CPR

cͲsuction mouth nose with bulb

• provide oxygen by resuscitation bag and mask

correctͲc

Suctioning with a bulb syringe may be the first and only action needed to clear the airway_C. Although – AͲ is appropriate for foreign body aspirations or choking, it is not indicated for this infant. BͲ us the next priority if the infant is not breathing or continues to be cyanotic. Newborns who are breathing usually become less cyanotic after the airway s cleared oxygen is administered(D).

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7, the nurse is assessing a postpartum client who delivered an 11 pound infant veginally 2 hours ago.The client’s fundus is fingerbreadths above the umbilicus, deviated to the right side, and boogy. After the client voids 200 ml of urine using a bedpan, what action should the nurse implement?

aͲ palpate the suprapubic region for distention

b.assist the client to the bathroom to void

cͲreevaluate the clinet in 15 minutes

dͲadminister a prn prescription for ocytocin

correctͲa

Neonatal maccrosoma increases the risk for iterine inertia, predisposing the client to uterine sinus bleeding, which cause the uterus to become boggy and displace, The client’s risk for postpartum bleeding is further increased by a full bladder, which should be assessed –AͲ after the client voids 200 ml using the bedpan. Before ambulating the client to the bathroomͲBͲ, thebladder should be assessed, Delaying assessment C doesn’t change the client’s uterine displacement, which is likely the result of a full bladder. Although oxytocin administrationͲDͲ may ultimately be indicated, further assessment, attempts to empty the bladder, and uterine massage should be implemented first.

• a client asks the nurse about the harmful effects of taking prescribed drugs during pregnancy. When

do drugs taken by a mother have the most significant effect on a fetus?

• 24 hours before delivery

• the first trimester

• first stage of labor

• six weeks prior to becoming pregnant

correctͲb

Drugs taken during the first trimester of pregnanacyͲBͲ cause the most concern for fetal development.Although(A,C,D) should be considered, teratogenic effects of drugs on embryological formation during the first trimester of pregnancy are most significant.

• the nurse observes a newborn with swelling of the scalp and suspects that is the result of birth

trauma. Which intervention should the nurse implement to differentiate between caput succedaneum and cephalhematoma?

• transilluminate the skull

• palpate the anterior fontanel

• examine the suture lines

• measure the head circumference

CorrectͲc

Cephalhematome is bound by suture lines while caput succedaneum crosses suture lines, so –CͲ aids in differentiating between the two conditions. AͲ is used to assess for the possibility of excess fluid or decreased brain tissue in the skill. B and D are not helpful in differentiaiting between the teo conditions

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