ATI RN Maternal Newborn

Practice 2019 A

1. 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 hemorrhage indicate that this

client is at the greatest risk for hypovolemic shock. This can

compromise the client’s vital organs, which can lead to death.

Therefore, the nurse’s priority is to massage the client’s fundus

to minimize blood loss.

2. 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 should be reported to the

provider?

• Late decelerations

Late decelerations are indicative of uteroplacental insufficiency.

Therefore, this is a contraindication for the administration of

oxytocin and should be reported to the provider.

3. 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 visual disturbances,

such as blurred vision, double vision, or dark spots in the visual

field.

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

vaginal hematoma. Which of the following manifestation should the

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. 

5. 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?

• 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.

6. 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 effect of 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 include amenorrhea,

weight gain, headache, nausea, breakthrough bleeding, and

breast tenderness.

7. 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.

8. 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.

9. 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.