ATI RN Maternal Newborn Online Practice 2019 A
1. A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the nurse expect?
a. Reports increased urinary output
i. MY ANSWER: Increased urinary output, nausea and vomiting, reports of
thirst, abdominal pain, constipation, drowsiness, and headaches are
manifestations of hyperglycemia. Other manifestations include weak rapid
pulse, fruity breath odor, urine positive for sugar and acetone, and a blood
glucose level greater than 200 mg/dL.
b. Diaphoresis. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry
skin is a manifestation of hyperglycemia.
c. Reports blurred vision. Blurred or double vision is a finding of hypoglycemia. A
report of dim vision is a manifestation of hyperglycemia.
d. Shallow respirations. Shallow respirations are a finding of hypoglycemia. Rapid
breathing is a manifestation of hyperglycemia.
2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which
of the following actions should the nurse take?
a. Administer penicillin G 2.4 million units IM to the client. The nurse should
administer penicillin G 2.4 million units IM to a client who has syphilis.
b. Instruct the client to schedule an annual pelvic examination. The nurse should
instruct the client to schedule a pelvic examination every 6 months.
c. Tell the client she will start medication for HIV immediately after delivery.
The nurse should tell the client that treatment for HIV will be during the
prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as
zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral
therapy (HAART) during pregnancy have been reported to decrease the
transmission of the virus to the newborn.
d. Report the client's condition to the local health department.
i. MY ANSWER. The nurse should report the condition to the local health
department. HIV is one of the conditions on the list of Nationally Notifiable
Infectious Conditions that is required to be reported.
3. 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 the medication?
a. Depression.
i. MY ANSWER. 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.
b. Polyuria. Fluid retention can occur due to an excess of estrogen. Polyuria is not a
common adverse effect of the medication.
c. Hypotension. Hypertension, rather than hypotension, is a common adverse effect
of combined oral contraceptives.
d. Urticaria. Urticaria is not a common adverse effect of combined oral
contraceptives.
4. 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 instruction should the nurse include
in the teaching?
a. "I can administer oxytocin 4 hours after the insertion of the medication."
i. MY ANSWER. 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.
b. "You will need a full bladder prior to the insertion of the medication."The nurse
should instruct the client to void prior to the administration of the medication.
c. "Remain in a side-lying position for 15 minutes after the medication is
inserted."The nurse should instruct the client to remain in a side-lying position for
30 to 40 min after the insertion.
d. "An antacid will be given 20 minutes prior to the insertion of the medication."The
nurse should avoid administering aluminum hydroxide and magnesium-containing
antacids with misoprostol.
5. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of
the following actions should the nurse take?
a. Administer antiviral medication. Currently, there are no antiviral medications
available to treat fifth disease.
b. Schedule an ultrasound examination.
i. MY ANSWER: The nurse should schedule serial ultrasound examinations to
monitor the fetus during the pregnancy to detect the possible development
of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth
restriction, fetal anemia, or stillbirth.
c. Administer Haemophilus influenzae type b vaccine. The Haemophilus influenzae
type b vaccine is given during infancy and childhood to protect against multiple
infections caused by Haemophilus influenzae type b, not fifth disease. Currently,
there are no vaccines to protect against fifth disease.
d. Schedule an indirect Coombs' test. An indirect Coombs' test determines whether
the client has antibodies to the Rh antigen. The titer determines the prenatal
client's sensitization and if there is Rh incompatibility.
Version | latest |
Category | Exam (elaborations) |
Release date | 2021-09-22 |
Pages | 29 |
Language | English |
Comments | 0 |
Sales | 0 |
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