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Ati maternal newborn final exam moitoso

Total Questions : 63

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Question 1:

A nurse is caring for a newborn client. The assessment findings include a high-pitched cry, increased muscle tone, frequent yawning, poor feeding with projectile vomiting, and tachypnea.
What condition does the nurse suspect?

Explanation

Choice A rationale

Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased

muscle tone, or projectile vomiting.

Choice B rationale

Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone,

yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.

Choice C rationale

Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-

pitched cry or projectile vomiting.

Choice D rationale

Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-

pitched cry or increased muscle tone.


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Question 2:

A nurse is caring for a client with irregular uterine contractions that are mild to palpation. FHR is 130/min with moderate variability and accelerations noted. The client has been ambulating in the hallway, took a warm shower, and is now resting in bed. The client rates pain of contractions at 3 on a 0 to 10 scale.
What potential condition does the nurse suspect?

Explanation

Choice A rationale

Umbilical cord compression typically results in variable decelerations in the fetal heart rate, not moderate variability or regular accelerations. It can lead to changes in fetal heart rate

patterns, but not regular mild contractions.

Choice B rationale

Dysfunctional labor refers to an abnormal labor pattern, including irregular uterine contractions. The described symptoms fit this condition, as they can cause mild pain and be

managed by ambulation, showers, and rest.

Choice C rationale

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, leading to fever, uterine tenderness, and foul-smelling amniotic fluid, not mild contractions and moderate

variability in FHR.

Choice D rationale

Iron deficiency anemia in pregnancy can cause fatigue, pallor, and shortness of breath but does not affect uterine contractions or fetal heart rate.


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Question 3:

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy.
Which of the following actions should the nurse take?

Explanation

Choice A rationale

Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.

Choice B rationale

Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.

Choice C rationale

Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.

Choice D rationale

Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.


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Question 4:

A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?

Explanation

Choice A rationale

Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.

Choice B rationale

Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.

Choice C rationale

An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.

Choice D rationale

Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.


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Question 5:

The nurse in an OB clinic is completing an intake assessment of a client at the first prenatal appointment. The client is currently 9 weeks pregnant. She had a miscarriage at 7 weeks and an ectopic pregnancy at 6 weeks that was treated with methotrexate. Her five-year-old son was born vaginally at 39 weeks and her three-year-old daughter was born vaginally at 35 weeks.
What is her GTPAL?

Explanation

Choice A rationale

G4T1 P1 A1 L2 implies the client has been pregnant 4 times, with 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. This does not include the correct number of

pregnancies or abortions for this client.

Choice B rationale

G5T2 P0 A2 L2 indicates 5 pregnancies, 2 term births, no preterm births, 2 abortions, and 2 living children. This does not correctly account for the preterm birth and abortion history

provided.

Choice C rationale

G5T1 P1 A2 L2 is the correct answer, as it denotes 5 pregnancies (including the current one), 1 term birth, 1 preterm birth, 2 abortions, and 2 living children, aligning with the client's

history.

Choice D rationale

G5T1 P1 A1 L3 indicates 5 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 3 living children. The client has only 2 living children, so this is incorrect.


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Question 6:

You admitted a client who experienced a precipitous labor.
What is the highest concern for maternal complication related to this type of labor?

Explanation

Choice A rationale

Precipitous labor is a rapid labor that typically lasts less than 3 hours. While it can result in trauma and complications, it does not inherently increase the risk for an operative delivery,

which is more often related to other factors like fetal distress or failure to progress.

Choice B rationale

Postpartum hemorrhage (PPH) is a significant concern with precipitous labor due to the rapid and forceful contractions that can cause uterine atony, leading to increased bleeding

after birth.

Choice C rationale

In a precipitous labor, the rapid delivery can cause vaginal lacerations, not a decreased risk. The swift passage of the baby through the birth canal increases the risk of tears and

trauma.

Choice D rationale

Neonatal sepsis is related to infections acquired during delivery but is not specifically linked to the speed of labor. The primary concern in precipitous labor is maternal trauma and

hemorrhage, not infection.


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Question 7:

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation.
Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

Explanation

Choice A rationale

Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to

ectopic pregnancy.

Choice B rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.

Choice C rationale

Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside

the uterus.

Choice D rationale

Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing

localized pain.


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Question 8:

A nurse is caring for a client who is on the electronic fetal monitor and the nurse notices that the client is experiencing tachysystole.
Which of the following describes tachysystole?

Explanation

Choice A rationale

A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.

Choice B rationale

When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.

Choice C rationale

Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.

Choice D rationale

Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.


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Question 9:

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
A. "It sounds like you are feeling sad that things didn't go as planned.”.

Explanation

Choice A rationale

Acknowledging the client’s feelings provides emotional support and validates her experience. This response opens the door for further discussion and support, which is crucial for emotional well-being.

Choice B rationale

Suggesting future possibilities does not address the client's current emotional state. It may come across as dismissive of her feelings and does not offer the immediate support she needs.

Choice C rationale

While emphasizing the health of the baby is positive, it can also be perceived as dismissive of the client's feelings and her disappointment about the birth experience.

Choice D rationale

Mentioning the resumption of sexual relations shifts the focus away from her emotional needs and can be inappropriate or insensitive in this context, failing to address her disappointment.


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Question 10:

A nurse is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia.
Which assessment finding would alert the nurse to suspect magnesium toxicity?

Explanation

Choice A rationale

A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.

Choice B rationale

Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.

Choice C rationale

Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.

Choice D rationale

Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .


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Question 11:

A nurse is assessing a newborn immediately following a scheduled cesarean delivery.
Which of the following assessments is the nurse's priority?

Explanation

Choice A rationale

Accidental lacerations are possible during a cesarean delivery, but they are typically managed quickly and are not the most critical issue immediately after birth.

Choice B rationale

Respiratory distress is the priority assessment for a newborn following a cesarean delivery because cesarean births can increase the risk of transient tachypnea or other respiratory complications due to the lack of labor-induced respiratory adaptation.

Choice C rationale

Hypothermia is a concern for all newborns, but respiratory distress takes precedence in the immediate post-delivery period, especially following cesarean delivery.

Choice D rationale

Acrocyanosis is a common and typically benign condition in newborns, not requiring immediate intervention compared to respiratory distress.


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Question 12:

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well.
Which of the following statements should the nurse make?

Explanation

Choice A rationale

Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.

Choice B rationale

While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.

Choice C rationale

Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.

Choice D rationale

This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.


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Question 13:

A nurse is caring for a client who was just diagnosed with an ectopic pregnancy and does not require surgery.
Which of the following medications can the nurse expect to administer?

Explanation

Choice A rationale

Dexamethasone is a corticosteroid and is not used for treating ectopic pregnancy.

Choice B rationale

Clomid (clomiphene citrate) is used to stimulate ovulation, not to treat ectopic pregnancy.

Choice C rationale

Methotrexate is a chemotherapeutic agent that effectively stops the growth of ectopic pregnancy cells, allowing the pregnancy tissue to be reabsorbed by the body.

Choice D rationale

Progesterone supports pregnancy and is not used to treat ectopic pregnancy.


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Question 14:

A nurse is caring for a client with a new diagnosis of a vaginal fistula.
The client states, "I don't understand how I got this.”. Which of the following is a potential cause of a vaginal fistula?

Explanation

Choice A rationale

Open heart surgery is unrelated to the development of vaginal fistulas.

Choice B rationale

Tissue trauma from childbirth can cause vaginal fistulas, as prolonged labor or obstetric interventions can damage vaginal tissue and lead to fistula formation.

Choice C rationale

Diabetes mellitus does not directly cause vaginal fistulas, although it can affect overall tissue health and healing.

Choice D rationale

Preeclampsia, while a serious pregnancy complication, is not a direct cause of vaginal fistulas.


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Question 15:

A nurse is assessing a client's risk of breast cancer.
Which of the following would not be included in the education about risks?

Explanation

Choice A rationale

A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.

Choice B rationale

Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.

Choice C rationale

Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.

Choice D rationale

Age less than 25 years is not a risk factor for breast cancer; risk increases with age.


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Question 16:

A nurse is assessing a newborn who was born at 42 weeks of gestation.
Which of the following findings should the nurse expect?

Explanation

Choice A rationale

Copious vernix is typically found on preterm newborns, not those born post-term.

Choice B rationale

Dry, cracked skin is a common finding in post-term newborns due to prolonged exposure to amniotic fluid.

Choice C rationale

Decreased subcutaneous fat is more likely in preterm newborns, while post-term newborns might lose some fat due to nutrient depletion.

Choice D rationale

Scant scalp hair is more common in preterm infants, whereas post-term infants usually have more developed hair. .


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Question 17:

A nurse is assisting a teenage client with breastfeeding.
The client asks, "How will I know when to feed my baby?" The nurse educates the client on infant feeding cues. Which of the following is a newborn feeding cue?

Explanation

Choice A rationale

Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.

Choice B rationale

Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.

Choice C rationale

Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.

Choice D rationale

Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.


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Question 18:

Which of the following statements about Group B Streptococcus (GBS) in pregnancy is true?

Explanation

Choice A rationale

GBS can be transmitted to the baby during both vaginal and cesarean deliveries if the mother is colonized with the bacteria. It is not limited to cesarean sections, hence why appropriate screening and treatment are essential.

Choice B rationale

GBS, although often harmless in the general population, can cause severe infections in newborns. This bacterium can be a source of severe neonatal infections like sepsis, pneumonia, and meningitis, necessitating preventive measures during pregnancy and delivery.

Choice C rationale

Screening for GBS is typically performed between 35 and 37 weeks of gestation, not at the first prenatal visit. This timing ensures accurate detection of the bacteria closer to the time of delivery.

Choice D rationale

Intravenous antibiotics during labor are recommended for mothers who test positive for GBS to prevent transmission to the baby. This intervention significantly reduces the risk of neonatal GBS infection.


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Question 19:

A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse identify as the priority?

Explanation

Choice A rationale

Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.

Choice B rationale

A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.

Choice C rationale

A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.

Choice D rationale

Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.


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Question 20:

 

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has preeclampsia. Suddenly, the client reports continuous severe abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

 

Explanation

Choice A rationale

Prolapsed cord involves the umbilical cord descending into the birth canal ahead of the fetus, which is a critical emergency but presents differently, typically with changes in fetal

heart rate and the cord being palpable or visible.

Choice B rationale

Abruptio placentae is characterized by the premature separation of the placenta from the uterine wall, which can cause severe abdominal pain, vaginal bleeding, and is a medical

emergency requiring immediate intervention to prevent maternal and fetal complications.

Choice C rationale

Placenta previa involves the placenta partially or completely covering the cervical opening, which can cause painless vaginal bleeding but does not typically present with severe

abdominal pain.

Choice D rationale

Incompetent cervix is associated with painless cervical dilation and potential preterm labor but not typically with severe abdominal pain and acute vaginal bleeding as seen with

abruptio placentae


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Question 21:

A nurse is caring for a newborn 4 hours after birth.
Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Explanation

Choice A rationale

Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.

Choice B rationale

Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not

mucus accumulation.

Choice C rationale

Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are

extremely high.

Choice D rationale

Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps

reduce the chances of bilirubin buildup.


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Question 22:

A nurse in the newborn nursery is caring for a group of newborns.
Which of the following assessments requires the nurse to notify the provider?

Explanation

Choice A rationale

A newborn who is 26 hours post-delivery and has had no urine output needs immediate attention. Lack of urine output for over 24 hours may indicate dehydration or renal issues. Immediate medical evaluation is required to identify underlying conditions and prevent complications such as acute kidney injury or sepsis.

Choice B rationale

Acrocyanosis, characterized by blueish discoloration of the extremities, is common in newborns during the first 24-48 hours of life and usually resolves on its own. It occurs due to immature blood circulation and is generally not a cause for concern.

Choice C rationale

Failure to pass meconium within the first 24 hours can be a sign of conditions like Hirschsprung's disease or cystic fibrosis, but it is not as immediately concerning as anuria (no urine output). Monitoring and further evaluation are necessary, but it does not require urgent provider notification.

Choice D rationale

A blood glucose level of 50 mg/dL in a newborn is within the lower limit of normal. While it's important to monitor, it does not necessitate immediate provider notification unless it continues to drop or other symptoms arise.


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Question 23:

A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?

Explanation

Choice A rationale

A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms

of preeclampsia appear.

Choice B rationale

A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.

Choice C rationale

A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.

Choice D rationale

A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.


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Question 24:

The nurse working in a clinic often screens her patients for postpartum depression (PPD). Identify the differences between postpartum depression and postpartum blues.

Explanation

Choice A rationale

Postpartum blues typically resolve within the first two weeks postpartum and involve mild symptoms like mood swings and irritability. In contrast, postpartum depression can persist

longer and requires treatment.

Choice B rationale

Symptoms of postpartum blues usually disappear without medical intervention, whereas postpartum depression often needs professional treatment to manage the more severe and

persistent symptoms.

Choice C rationale

Postpartum depression can impair a mother's ability to care for herself and her baby safely, requiring intervention to prevent harm. Postpartum blues do not typically cause such severe

functional impairment.

Choice D rationale

Postpartum depression may require antidepressants for treatment due to its severity. Postpartum blues generally do not necessitate such interventions and are managed through

support and reassurance.

Choice E rationale

Postpartum depression can occur at any time within the first 12 months after delivery, while postpartum blues are usually confined to the initial two weeks postpartum.


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Question 25:

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?

Explanation

Choice A rationale

Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.

Choice B rationale

Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.

Choice C rationale

Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.

Choice D rationale

Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .


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