ATI CAPSTONE MATERNAL NEWBORN ASSESSMENT Questions and Answers (2022/2023) (Verified Answers)

Severe preeclampsia symptoms with seizure activity or coma.
Eclampsia

A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction.
HELLP syndrome

Hypertension beginning after the 20th week of pregnancy with no proteinuria.
Gestational Hypertension

Impaired tolerance to glucose with the first onset or recognition during pregnancy.
Gestational Diabetes

Severe morning sickness with unrelenting, excessive nausea or vomiting that prevents adequate intake of food and fluids.
Hyperemesis gravidum

Hypertension beginning after the 20th week of pregnancy with 1 to 2+ proteinuria and a weight gain of more than 2 kg per week in the second and third trimesters.
Mild preeclampsia

24-48 hours after birth: dependent, passive; focuses on own needs; excited, talkative
taking in

Focuses on family and individual roles.
letting go

2nd-10th day postpartum, or up to several weeks: focuses on maternal role and care of the newborn; eager to learn; may develop blues.
taking hold

A postpartum client’s fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following interventions should the nurse take?
Assist the client to void then reassess the fundus.
Correct
Displacement of the uterus is a sign of bladder distention. The nurse should assist the client to void then reassess the fundus

Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
Cold stress
Correct
The use of a radiant warmer following delivery prevents cold stress which can lead to increased metabolism and physiological demands.

A client has been prescribed raloxiphine. As the nurse you know that raloxiphine is used to treat:
b. Osteoporosis
Correct
Raloxiphine (Evista) is used to prevent and treat bone loss (osteoporosis) in women after menopause. It is not used for migraines, hypertension, or heart disease.

A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
Change the client’s position.

Late decelerations are associated with insufficient placental perfusion which requires immediate intervention to restore adequate blood flow. Changing the client’s position will displace the weight of the uterus off of the vena cava and thus increase maternal circulation to the placenta.

A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
Maintain an eye mask over the newborn’s eyes. CorrectThe nurse should maintain an eye mask over the newborn’s eye to protect the corneas and retinas from phototherapy.

A pregnant client’s last menstrual period was May 4th, 2013. What is this client’s estimated delivery date using Naegele’s Rule?
d. February 11, 2014 CorrectCorrect. The estimated date of birth is February 11th, 2014. To determine the due date using Naegele’s rule, 3 months is subtracted from the date of the last menstrual period then 7 days and 1 year are added.

A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?
c. Naloxone is used to reverse the effects of narcotics such as demerol.

A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education?
a. “If I miss three pills I will double up each day until back on schedule.”

In the event of a client missing a dose the nurse should instruct the client that if one pill is missed to take as soon as possible. If two or three pills are missed the client should follow the manufacturer’s instructions and use an alternative form of contraception.

A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?
c. Hormonal changes with a rapid decline in estrogen and progesterone levels CorrectCorrect! Risk factors for postpartum depression include hormonal changes with a rapid decline in estrogen and progesterone levels; postpartum physical discomfort and/or pain; individual socioeconomic factors; decreased social support system; anxiety about assuming new role as a mother; unplanned or unwanted pregnancy; history of previous depressive episode; low self-esteem; and a history of domestic violence.

A laboring client’s membranes have just ruptured. What is the nurse’s next action?
Assess fetal heart rate pattern

An antepartal client is Rh negative and understands that she will receive a RhoGAM injection during her pregnancy. The client asks the nurse if she will also receive a RhoGAM injection after the birth of her baby. The client will receive RhoGAM after the birth if blood tests are:
d. Mother Rh negative; Coombs negative; baby Rh positive CorrectCorrect. If the baby is Rh negative, the mother will not be exposed to positive antigens and will not need RhoGAM. An indirect Coombs test indicates the presence or absence of antibodies. If the indirect Coombs test is positive, the mother’s blood is producing anti-Rh (D) antibodies, and it is too late for RhoGAM to do any good.

A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
d. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux.
The effects of progesterone on the GI tract include relaxation of the cardiac sphinter and delayed gastric emptying.

A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
d. Reduce intake of caffeinated and carbonated beverages.

Correct. The nurse should instruct the client to limit her daily fluid intake; reduce the intake of fluids and foods that may be irritating to the urinary system and bladder; to avoid constipation by increasing fiber in the diet; and to perform Kegel exercises regularly to strengthen the pelvic floor.

A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?
b. Muscle and joint pain CorrectCorrect. Muscle and joint pain are potential side effects of anastrozole and can be treated with mild analgesic as prescribed.

During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
a. An irregularly shaped, nontender lump is palpable in the right breast. CorrectCorrect. Irregularly shapped, nontender lumps are consistent with the diagnosis of breast cancer.

Which of the following would increase a client’s risk of ovarian cancer?
c. Endometriosis
Correct. Endometriosis has shown to increase the risk of developing ovarian cancer

A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is
presumptive

CORRECT sign of pregnancy. Fill in the blank with the correct choice: presumptive, probable, possible, positive.

Quickening is a presumptive sign of pregnancy because self reported feelings of fetal movement could be gas or peristalsis instead of actual fetal movement. Probable signs of pregnancy include positive serum pregnancy tests, Chadwick’s sign, and Goodell’s sign. Positive signs of pregnancy include fetal heart tones by doppler or fetal stethoscope and fetal movement palpated by an examiner.

For breast engorgement, fresh cabbage leaves placed inside the bra can help alleviate pain associated with breast engorgement. T/F?
TRUE

A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
petroleum jelly

Bathing a newborn by submerging the infant in water is allowed 72 hours after birth. T/F?
False.

Bathing a newborn by submerging in water should not occur until the cord has fallen off. Most cords fall off within the 10 to 14 days.

A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
c. Cesarean birth
Correct. Cesarean birth doubles the risk for deep-vein thrombosis.

Cesarean birth doubles the risk for deep-vein thrombosis. Other risk factors include pregnancy, operative vaginal birth, pulmonary embolism, immobility, obesity, smoking, multiparity, age greater than 35 years, history of thromboembolism and diabetes mellitus.

Disadvantages of a nonstress test include a high rate of false nonreactive results with fetal movement due to sleep cycle of the fetus and nicotine use. T/F?
TRUE

Prior to an amniocentesis, what action by the client will need to be completed?
a. Empty the bladder. CorrectCorrect–Prior to the amniocentesis procedure the nurse will instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture.

A client is being treated with eclampsia. What is a priority nursing intervention?
Assess for hyperreflexia.

Progressive change in effacement
True labor

Bloody show not present
False Labor

Fetus moves to anterior position
True Labor

Contractions intermittent and painless
False Labor

Contractions regular in frequency
True Labor

When a newborn demonstrates respiratory distress and routine suctioning with the bulb syringe is unsuccessful, the nurse will deliver chest thrusts.
True

If bulb suctioning is unsuccessful, mechanical suction and/or back blows and chest thrusts can be used, as well as the institution of emergency procedures.

If bulb suctioning is unsuccessful, mechanical suction and/or back blows and chest thrusts can be used, as well as the institution of emergency procedures.

To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a
Supine position

A nurse is reinforcing teaching with a client who is postpartum and plans to breastfeed their newborn. Which of the following statements by the
client indicates an understanding of the teaching?

1. “I should add 500 calories per day to my diet.”
2. “I will use antibacterial soap and warm water to wash my breasts.”
3. “Breastfeeding is a reliable method of birth control.”
4. “If my nipples become cracked and red, I will apply hydrocortisone cream.”
5. “I should add 500 calories per day to my diet.”

A nurse is collecting data from an infant who has Hirschsprung’s disease. Which of the following manifestations should the nurse expect?

1. Abdominal distention
2. Steatorrhea
3. Blood-tinged emesis
4. Dysphagia
5. Abdominal distention

A nurse is collecting data from a client who is 6 weeks postpartum. The client tells the nurse,
“I am not a good mother. My baby doesn’t like me.”
Which of the following actions should the nurse take?

1. Advise the client that most new mothers experience these feelings
2. Ask the client if they have had thoughts about harming their infant.
3. Explain to the client they are experiencing the “baby blues.”
4. Take the client to the emergency department.
5. Ask the client if they have had thoughts about harming their infant.

A nurse is reinforcing teaching with an adolescent client who uses inhalers for the treatment of asthma. Which of the following statements by the
client indicates an understanding of the teaching?

1. “I will wait 15 seconds between puffs when using my levalbuterol inhaler.
2. “I need to use my fluticasone inhaler when I start to wheeze during exercise.”
3. “I need to use my levalbuterol inhaler before I exercise.
4. “I will stop using my fluticasone inhaler if I experience restlessness.”
5. “I need to use my levalbuterol inhaler before I exercise.

A nurse is reinforcing teaching with a parent of an infant who has diaper dermatitis and a new prescription for zinc oxide ointment. Which of the
following statements by the parent indicates an understanding of the teaching?

1. “I will wash off the ointment with each diaper change.”
2. “I should shake talcum powder onto the reddened areas.”
3. “I should dry the diaper area with a hair dryer on the lowest setting.”
4. “I will use moist disposable wipes that are detergent free.”
5. “I will use moist disposable wipes that are detergent free.”

A nurse is reinforcing teaching with a parent of a school-age child who has tonic-clonic seizures. Which of the following statements should the
nurse make regarding care during a seizure?

1. “You should offer your child sips of clear liquids.”
2. “You should gently restrain your child using both of your arms.”
3. “You should place your child’s head on a pillow.”
4. “You should give rectal diazepam to your child at the onset of the seizure.”
5. “You should place your child’s head on a pillow.”

A nurse is reviewing laboratory reports for four antepartum clients. Which of the following laboratory results should the nurse report to the
provider?

1. 2-hr postprandial glucose 105 mg/dL
2. Negative group B streptococcus -hemolytic
3. Hgb 13 g/dL
4. 2+ proteinuria
5. 2+ proteinuria

A nurse is assisting in the care of a child who is receiving IV cefuroxime when the child begins to have difficulty breathing. Which of the following
actions should the nurse take first?

1. Obtain vital signs.
   2.Stop the IV infusion.
2. Administer epinephrine IM.
3. Monitor intake and output.
4. Stop the IV infusion.

A nurse is discussing growth and development milestones with the parents of a 3-year-old preschooler. Which of the following statements by a parent indicates to the nurse that the preschooler is meeting the expected benchmarks of other preschoolers in this age group?

1. “My child uses scissors to cut out the outline of an object.”
2. “My child can copy triangle shapes onto paper.”
3. “My child can ride a tricycle.”
4. “My child can throw a ball overhead.”
5. “My child can ride a tricycle.”

A nurse is assisting with the care of an adolescent who has a partial-thickness burn. When observing the site of the burn, which of the following
clinical manifestations should the nurse expect?

1. Brown in color
2. Leathery appearance
3. Visible ligaments
4. Blister formation
5. Blister formation

A nurse on a pediatric unit is assisting with the admission of a toddler who has pneumonia. The nurse should identify that which of the following
findings is an expected behavior of hospitalization?

1. Experiences separation anxiety
2. Fears a loss of control
3. Feels hospitalization is punishment
4. Develops body image disturbance
5. Experiences separation anxiety

A nurse is assisting in the admission of a client who had recently given birth and is presenting to the emergency department with acute opioid
toxicity. Which of the following findings should the nurse expect?

1. Hypothermia
2. Hypertension
3. Diaphoresis
4. Mydriasis
   1.

A nurse is reinforcing teaching about perception of death with the guardians of an adolescent who has a terminal illness. Which of the following
statements should the nurse make?

1. “Adolescents tend to be more concerned with their appearance than the dying process.”
2. “Many adolescents imagine death as a type of monster.”
3. “Adolescents tend to believe their own actions might have caused their terminal illness.”
4. “Many adolescents don’t understand that death is permanent.”
   1

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and requires phototherapy. Which of the following
interventions should the nurse include?

1. Apply lotion to the newborn’s skin twice per day.
2. Check the newborn’s blood glucose every 2 hr.
3. Swaddle the newborn during the treatment.
4. Remove the newborn’s eye mask during feedings.
   4

A nurse is assisting with the care of a client who is experiencing a postpartum hemorrhage. Which of the following actions should the nurse take?
(Select all that apply.)

1. Firmly massage the fundus.
2. Administer oxygen via a nonrebreather face mask.
3. Ensure the client has IV access.
4. Prepare the client for an amnioinfusion.
5. Give the client Rh(D) immune globulin.
   1,2,3

A nurse is caring for a client who is postpartum, reports an allergy to aspirin, and states that they are in pain. The nurse should identify which of
the following medications as safe to administer to the client?

1. Ibuprofen
2. Acetaminophen
3. Naproxen
4. Celecoxib
   2

A nurse is caring for an adolescent who states an intention to self-harm. Which of the following actions should the nurse take first?

1. Maintain continuous observation of the adolescent.
2. Apply wrist restraints to the adolescent.
3. Collect data about the adolescent’s mental status.
4. Obtain consent from the adolescent’s guardian for the application of restraints.
   3

A nurse is reinforcing teaching with a newly licensed nurse about the various indications of pregnancy. Which of the following findings should the
nurse include in the teaching as a presumptive sign of pregnancy? (Select all that apply.)

1. Breast changes
2. Ballottement
3. Urinary frequency
4. Nausea
5. Positive pregnancy test
   1,3,4

A nurse is preparing to administer an intermittent enteral feeding to a child who has an NG tube in place. Which of the following actions should
the nurse take first?

1. Place the child in an upright position.
2. Verify the position of the NG tube
3. Determine the gastric residual volume.
4. Flush the child’s NG tube with sterile water.
   1

A nurse is caring for an infant who has pertussis. Which of the following precautions should the nurse implement?

1. Airborne
2. Droplet
3. Standard
4. Neutropenic
   2

A nurse is reinforcing teaching with a parent of a child who has a greenstick fracture. Which of the following information should the nurse include
in the teaching?

1. The bone bends, causing a microscopic fracture line.
2. The fracture does not cross through the bone.
3. The bone is compressed, causing a raised area at the fracture site.
4. The fracture completely divides the bone.
   2

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is scheduled for a nonstress test. Which of the following
statements should the nurse make?

1. “You will be lying flat on your back for the duration of the test.”
2. “At some point during the test, you will need to lightly brush your palms across your nipples for 2 minutes.”
3. “Do not eat or drink anything for 4 hours prior to the test.”
4. “Press the button you are given when you feel the baby moving during the test.”
   4

A nurse is collecting data from a 6-month-old infant during a well-child visit. Which of the following findings should the nurse expect? (Select all
that apply.)

1. Presence of Moro reflex
2. Birth weight has doubled
   3.Closed posterior fontanel
   4.Able to sit unsupported
3. Able to move from back to front
   2,3,5

A nurse is planning to assist with Leopold maneuvers on a client who is at 37 weeks of gestation. Which of the following actions should the nurse
plan to take?

1. Ask the client to empty their bladder.
2. Assist the client into a left-lateral position.
3. Apply an external fetal monitor to the client’s abdomen.
4. Instruct the client to perform nipple stimulation.
   1

A nurse in a provider’s office is planning to administer immunizations to an 11-year-old child who is up to date with current recommendations.
Which of the following immunizations should the nurse plan to administer?

1. Hepatitis B (Hep B)
2. Measles, mumps, rubella (MMR)
3. Tetanus, diphtheria, and pertussis (Tdap)
4. Pneumococcal (PCV)
   3

A nurse is reviewing the laboratory report of an adolescent client who has menorrhagia. Which of the following laboratory results should the
nurse report to the provider?

1. WBC count 10,000/mm3
2. Hgb 6.8 g/dL
3. Creatinine 0.8 mg/dL
4. Potassium 3.5 mEq/L
   2

A nurse is reinforcing teaching to a client who is pregnant regarding a 1-hr glucose tolerance test (GTT). Which of the following statements by the
client indicates an understanding of the test?

1. “This test is to check if my baby has diabetes.”
2. “If the result is higher than normal, I will need to be on insulin the rest of my life.”
3. “If1 forget and eat before the test, then I won’t be able to have the test done.”
4. “If the results are high, then I need another test to see if I have gestational diabetes.”
   4

A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following
statements should the nurse include?

1. “Drinking warm tea before bed can be helpful.”
2. “Doing relaxation exercises before bed can be helpful.”
3. “Sleeping on your right side can be helpful.”
4. “Soaking in a hot tub for 60 minutes can be helpful.”
   2

A nurse is reinforcing teaching with the parent of a school-age child who has ADHD and a new prescription for a methylphenidate transdermal
patch. Which of the following statements by the parent indicates an understanding of the teaching?

1. “I should place a heat pack on the patch to improve adhesion for 5 minutes after applying
2. “I should place the patch on the back side of my child’s arm.”
3. “I will reinforce the patch edges with clear tape if they don’t lie flat.”
4. “I will leave the patch in place for no more than 9 hours.”
   4

A nurse is reinforcing teaching with a client who is postpartum and is taking docusate sodium to prevent constipation. Which of the following
instructions should the nurse include?

1. “Take this medication every day for regular bowel movements.”
2. “Take the medication with mineral oil.”
3. “Decrease dietary fiber intake while taking this medication.”
4. “Take the medication with a full glass of water.”
   4

A nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following statements by the adolescent
indicates an understanding of the teaching?

1. “I will discard insulin bottles 60 days after opening.”
2. “Before I exercise, I will need to take an extra 10 units of insulin.”
3. “If I feel dizzy, I will drink 4 ounces of orange juice.”
4. “A hemoglobin Alc of 9 percent is a good goal.”
   3

A nurse is reinforcing teaching about a biophysical profile (BPP) with a client who is at 38 weeks of gestation. Which of the following statements
should the nurse include in the teaching?

1. “This test measures amniotic fluid volume.”
2. “You will receive Rh, (D) immune globulin prior to this test.”
3. “This test is used to assess uterine activity.”
4. “Your bladder needs to be full to perform this test.”
   1

A nurse is caring for a 9-year-old client who is immediately postoperative. The client is nonverbal and has both cognitive and developmental
delays. Which of the following pain scales should the nurse use to evaluate the client’s pain?

1. FACES scale
2. Numerical scale
3. )FLACC pain assessment scale
4. Visual analog scale
   3

A nurse in an antepartum clinic is reinforcing teaching with a pregnant client about breastfeeding. Which of the following statements by the client
indicates an understanding of the teaching?

1. “I should start trying to breastfeed within an hour of having my baby
2. “I should give my baby formula between feedings if he loses 5 percent of his birth weight.”
3. “I should let my baby nurse for 10 minutes from each breast when he is hungry.”
4. “I should offer my baby a pacifier after breastfeeding him if he is fussy.”
   1

A nurse is caring for a client who is at 12 weeks of gestation and is prescribed a high-protein diet. Which of the following foods should the nurse
recommend as containing the highest amount of protein?

1. One cup of oatmeal
2. One cup of tofu
3. One cup of brown rice
4. One cup of kale
   2

A nurse is assisting with initial newborn data collection immediately following delivery. The nurse should identify that which of the following
findings requires further evaluation?

1. Substernal retractions
2. Mongolian spots
3. Positive Babinski reflex
4. Erythema toxicum
   1

A nurse in an urgent care clinic is contributing to the plan of care for a child who has suspected epiglottitis. Which of the following interventions
should the nurse plan to include?

1. Initiate contact precautions
2. Monitor pulse oximetry.
3. Obtain a throat culture.
4. Administer epinephrine IM.
   2

A nurse is evaluating the parenting styles of a group of parents of school-age children. Which of the following statements by a parent indicates the
use of a permissive parenting style?

1. “We decide how our children spend their time.
2. “We expect our children to follow directions without questioning us.
3. “We allow our children the freedom to decide their own behavior.”
4. “We explain to our children the reasoning behind the rules that we make.
   3

A nurse is reinforcing teaching with an adolescent about subdermal progesterone contraception devices. Which of the following statements by the
client indicates an understanding of the teaching?

1. “I will need to have this device replaced every 3 years.”
2. “This device will protect me from STIs.”
3. “I should call my provider if I notice thick white discharge in my underwear.”
4. “I need to decrease the amount of milk I drink while I have this device.’
   1

A nurse is collecting data from an adolescent who is postoperative and is receiving morphine for pain. Which of the following findings is the
nurse’s priority?

1. Respiratory rate 10/min
2. Bladder distention
3. BP 108/64 mm Hg
4. Nausea and vomiting
   1

A nurse is contributing to the plan of care for a client 48 hr following cesarean birth. Which of the following nonpharmacologic interventions
should the nurse include to reduce pain from intestinal gas?

1. Provide the client with a carbonated beverage
2. Encourage the client to lie on their right side.
3. Encourage the client to ambulate.
4. Provide the client with straws for beverages.
   3

A nurse is planning to collect data on the pain level of a 3-year-old child. Which of the following pain rating scales should the nurse plan to use?

1. Visual analog scale
2. FACES
3. )Word-graphic
4. Numeric
   2

A nurse is assisting with the care of a client who is receiving epidural anesthesia for pain management during labor. Which of the following actions
should the nurse take?

1. Remind the client to void every 4 hr.
2. )Encourage the client to alternate from side to side every 2 hr.
3. Raise the four side rails on the client’s bed.
4. Monitor the client’s blood pressure.
   4

A nurse is assisting with the care of a client who is at 36 weeks of gestation and experienced premature rupture of membranes. Which of the
following actions should the nurse take?

1. Administer glucocorticoids
2. Monitor the client’s temperature.
3. Give calcium gluconate.
4. Prepare the client for an amniocentesis.
   2

A nurse is preparing to administer immunizations to a 4-year-old child who is up to date on current immunizations. Which of the following
immunizations should the nurse plan to administer?

1. Rotavirus
2. Hepatitis B (Hep B)
3. Varicella
4. Haemophilus influenza (Hib)
   3

A nurse is caring for a client who is in labor and tested positive for group B streptococcus -hemolytic. Which of the following actions should the
nurse take?

1. Reinforce to the client that they should not breastfeed after delivery.
2. Maintain contact precautions for the client.
3. Obtain a pharyngeal culture from the client.
4. Reinforce to the client that they will receive IV antibiotic prophylaxis.
   4

A nurse is collecting data from a school-age child who has a newly diagnosed brain tumor. Which of following findings should the nurse expect?

1. Insomnia
2. Negative Babinski sign
3. Increased appetite
4. Incoordination
   4

A nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse expect?

1. The infant has a pincer grasp.
2. The infant drops objects with the expectation of someone picking them up
3. The infant makes babbling sounds.
4. The infant crawls on their hands and knees.
   3

A nurse is collecting data from a 4-year-old child during a well-child visit. Which of the following findings should the nurse expect?

1. Positive Babinski sign
2. Birth height has doubled
3. Birth weight has doubled
4. Presence of permanent teeth
   2

A nurse is caring for an adolescent who lives on their own and is refusing treatment. Which of the following statements should the nurse make?

1. “You can only refuse treatment for STI testing.”
2. “You will need a parent or guardian to make this medical decision for you.”
3. “You must be married in order to make your own health care decisions.”
4. You have the right to refuse this treatment.”
   4

lOMoARcPSD| 22891787 CAPSTONE MATERNAL NEWBORN ASSESSMENT EXAM QUESTIONS AND ANSWERS 1. A nurse is reviewing the laboratory results for a client who is at 29 weeks.… the provider? WBC count 11,000/mm³ Hgb 11,2 g/dL Hct 34% Platelets 140,000/mm³ 2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take? Restrict protein intake to less than 40 g/day. Initiate seizure precautions for the client. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr. Encourage the client to ambulate twice per day. 3. A nurse is caring for a client who is in the transition phase of labor. Which of the following… Assist the client to void every 3 hr. Monitor contractions every 30 min. Place the client into a lithotomy position. Encourage the client to use a pant-blow breathing pattern. 4. A nurse is teaching the parents of a newborn how to care for their child’s uncircumcised penis. Which of the following instructions should the nurse include? Retract the foreskin until you feel resistance. Use a cotton swab to clean under the foreskin. Apply petroleum jelly to the foreskin. Wash the penis once per day with soup and water.
lOMoARcPSD| 22891787 5. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings show potential prenatal complication? Periodic tingling of fingers Absence of clonus Leg cramps Blurred vision 6. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take? Administer oxytocin to the client via intravenous infusion. Apply oxygen at 2 L/min via nasal cannula. Prepare for insertion of an intrauterine pressure catheter. Assist the client into the knee-chest position. 7. A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching? A peanut butter sandwich on wheat bread. A sliced apple and red grapes. A chocolate chip cookie with a glass of skim milk. A scrambled egg with cheddar cheese. 8. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following….. A client who gave a birth 1 day ago and needs Rh˳(D) immune globulin. A client who gave a birth 3 days ago and reports breath fullness. A client who gave a birth 12 hr. ago and reports and increase in urinary output. A client who gave a birth 8 hr. ago and is saturating a perineal pad every hour.
lOMoARcPSD| 22891787 9. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome? Hyporeactivity Excessive high-pitched cry Acrocyanosis Respiratory rate of 50/min 10. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations…Which of the following actions should the nurse take first? Prepare the equipment necessary to initiate an amnioinfusion. Administer oxygen at 10 L/min via nonrebreather face mask. Discontinue the infusion of oxytocin. Place the client in a left lateral position. 11. A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take? Initiate continuous monitoring of the FHR. Administer a dose of betamethasone. Check the cervix for dilation every 8 hr. Request that the provider prescribe misoprostol PRN. 12. A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? BUN 35 mg/dL Hgb 15 mg/dL Bilirubin 0.6 mg/dL Hct 37%
lOMoARcPSD| 22891787 13. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance … that crosses the suture line. The nurse should identify the swellings as which of the following….? Nevus flammeus Caput succedaneum Cephalohematoma Erythema toxicum 14. A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect? Hypotonicity Moderate tremors of the extremities Axillary temperature 36.1°C (96.9° F) Excessive sleeping 15. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion? Contraction frequency every 3 min Contraction duration of 100 seconds Fetal heart rate with moderate variability Fetal heart rate of 118/min 16. A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following should the nurse include? (Select all that apply.) Nulliparity History of breastfeeding (???) Previous use of oral contraceptives History of breast cancer Hormone replacement therapy
lOMoARcPSD| 22891787 17. A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal…. Which of the following actions should the nurse take first? Change the client’s position. Palpate the uterus to assess for tachysystole. Increase the client’s IV infusion rate. Administer oxygen at 10 L/min via nonrebreather mask. 18. A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical … effect of epidural anesthesia? Polyuria Hypertensi on Pruritus Dry mouth 19. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer? Ampicillin Azithromyc in Ceftriaxone Acyclovir