ATI LPN Maternal Newborn Exam

Question 1: View A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

A. Place the newborn in a radiant warmer. B. Initiate phototherapy. C. Obtain blood glucose by heel stick. D. Measure the newborn's blood pressure.

Explanation

Rationale:

A. Placing the newborn in a radiant warmer may be indicated for temperature instability, but it does not directly address the observed signs of respiratory distress, jitteriness, and lethargy.

B. Initiating phototherapy is typically done for newborns with hyperbilirubinemia (jaundice), which is not indicated by the symptoms described.

C. Obtaining blood glucose by heel stick is the priority action because the symptoms described could indicate hypoglycemia, especially in a newborn. Prompt assessment and management of blood glucose levels are essential.

D. Measuring the newborn's blood pressure is not typically a priority in this situation unless there are specific indications, such as suspected cardiovascular abnormalities.

Question 2: View A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?

A. Facial edema B. Urinary frequency C. Decreased energy D. Mood swings

Explanation

Rationale:

A. Facial edema can be a sign of preeclampsia, a serious complication of pregnancy characterized by high blood pressure and protein in the urine. Prompt notification of the healthcare provider is essential for further evaluation and management.

B. Urinary frequency is common in pregnancy due to hormonal changes and an enlarging uterus but does not typically require immediate notification of the healthcare provider unless accompanied by other concerning symptoms.

C. Decreased energy is a common symptom in early pregnancy and may not necessarily indicate a need for immediate notification of the healthcare provider unless it is severe or accompanied by other symptoms.

D. Mood swings are also common in pregnancy due to hormonal changes and may not require immediate notification of the healthcare provider unless they are severe and significantly affecting the client's well-being.

Question 3: View A nurse is reinforcing teaching about quickening with a client who is at 6 weeks of gestation.
Which of the following information should the nurse include?

A. Quickening starts during the last weeks of pregnancy. B. Quickening occurs between the second and third months of pregnancy. C. Quickening occurs between the fourth and fifth months of pregnancy. D. Quickening starts soon after implantation.

Explanation

Rationale:

A. Quickening refers to the first perception of fetal movements by the mother and typically occurs around 16 to 20 weeks of gestation, which is during the second trimester, not the last weeks of pregnancy.

B. Quickening usually occurs later than the second and third months of pregnancy. During the second and third months, the fetus is still very small, and fetal movements are not typically felt by the mother.

C. Quickening occurs between the fourth and fifth months of pregnancy, typically around 16 to 20 weeks of gestation. This is when the fetus has grown large enough for the mother to feel movements.

D. Quickening does not start soon after implantation, which occurs in the early weeks of pregnancy before the fourth or fifth month.

Question 4: View A nurse is caring for a client who is at 20 weeks of gestation and tells the nurse that she is concerned that exercising might pose risks to her pregnancy. Which of the following statements should the nurse make?

A. "Moderate exercise can help improve your circulation." B. "It is a good idea to increase your weight-bearing exercises." C. "Be careful about exercises that include stretching." D. "You should rest for 5 minutes following exercise."

Explanation

Rationale:

A. "Moderate exercise can help improve your circulation" is an appropriate statement because regular, moderate exercise during pregnancy can help improve circulation, reduce swelling, and promote overall well-being for both the mother and the baby.

B. Increasing weight-bearing exercises may not be advisable without proper guidance as excessive strain or impact can pose risks, especially in later stages of pregnancy.

C. Stretching exercises are generally safe during pregnancy and can help maintain flexibility and alleviate discomfort, so advising caution without further context may not be necessary.

D. While it's important to rest as needed during exercise, specifying a fixed rest period of 5 minutes may not be applicable to all situations and may not address the client's concerns about exercise risks.

Question 5: View A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit.Physical Examination 0900
Lungs clear to auscultation in all lobes, anterior, posterior, and lateral Abdomen gravid and soft to palpation. Fundal height 37 cm. Facial edema observed as well as 3 edema in the lower extremities. Mild anxiety. Patellar reflex 3, clonus negative. Fetal heart rate 172/min. BP 143/85. A nurse is assisting in the care of a client who is 36 weeks of gestations and reported to the clinic for a routine visit. Which of the following findings should the nurse report to the provider? (Select all that apply)

A. Blood pressure B. Respiratory rate C. Gastrointestinal assessment findings D. Cerebral manifestations E. Deep tendon reflexes F. Fetal heart rate

Explanation

Rationale:

A. Blood pressure: Changes in blood pressure, particularly elevated blood pressure, could indicate gestational hypertension or preeclampsia, which require prompt evaluation and management, especially in the context of observed facial and lower extremity edema.

B. Respiratory rate: While respiratory rate is important, the given physical examination does not suggest any abnormalities in respiratory status. Therefore, it is not a priority finding to report in this scenario.

C. Gastrointestinal assessment findings: Gastrointestinal findings are not typically pertinent to the assessment of a routine prenatal visit at 36 weeks of gestation unless the client presents with specific gastrointestinal symptoms or concerns.

D. Cerebral manifestations: Any cerebral manifestations such as changes in consciousness, severe headache, visual disturbances, or epigastric pain could indicate preeclampsia or other neurological issues and should be reported for further evaluation.

E. Deep tendon reflexes: A patellar reflex of 3 may indicate hyperreflexia, which, in conjunction with other signs, could suggest preeclampsia. Therefore, it should be reported to the provider for further assessment.

F. Fetal heart rate: Monitoring fetal well-being is essential in prenatal care. Any abnormalities in fetal heart rate, such as persistent tachycardia or bradycardia, should be reported promptly for further evaluation.

Question 6: View A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination?

A. Rupture of the fetal membranes B. Infection C. Profound bleeding D. Preterm labor

Explanation

Rationale:

A. Rupture of the fetal membranes is a risk associated with pelvic examinations, but in the context of placenta previa, the primary concern is the risk of causing bleeding from the placenta, not necessarily rupture of the fetal membranes.

B. Infection is a potential risk of any invasive procedure, including pelvic examinations, but it is not the primary reason to avoid pelvic examinations in a client with placenta previa.

C. Profound bleeding is the primary reason to avoid pelvic examinations in a client with placenta previa. The placenta is positioned over or near the cervical os, and any manipulation of the cervix can cause significant bleeding due to disruption of the placental vessels.

D. Preterm labor is not directly related to performing a pelvic examination in a client with placenta previa.

Question 7: View A nurse is reinforcing teaching with a newly licensed nurse about the administration of depot medroxyprogesterone. Which of the following Instructions should the nurse include in the teaching?

A. "Administer depot medroxyprogesterone every 6 to 8 weeks." B. "Massage the site after you administer the medication." C. "Give the medication intramuscularly." D. "Initiate depot medroxyprogesterone 14 days after the client's first day of her menstrual cycle."

Explanation

Rationale:

A. "Administer depot medroxyprogesterone every 6 to 8 weeks" is correct, as it is the recommended dosing interval for depot medroxyprogesterone injections for contraception.

B. "Massage the site after you administer the medication" is not necessary for depot medroxyprogesterone injections and may even cause discomfort or tissue damage.

C. "Give the medication intramuscularly" is the correct route of administration for depot medroxyprogesterone injections. It is typically administered into the deltoid or gluteal muscle.

D. "Initiate depot medroxyprogesterone 14 days after the client's first day of her menstrual cycle" may be appropriate for some clients, but it depends on the specific indication for the medication. This instruction is not universally applicable for all clients receiving depot medroxyprogesterone.

Question 8: View A nurse is assisting with a community program to educate adolescents about contraception.
After the class, a 15-year-old girl asks the nurse which method is best for her to use. Which of the following statements is an appropriate nursing response?

A. "Because of your age, we need your parents' consent for an examination, and then we'll talk." B. "The doctor can best help you with that after your physical examination." C. "Before I can help you with that question, I need to know more about your sexual activity." D. "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?"

Explanation

Rationale:

A. Requiring parental consent for an examination may not be necessary, especially if the adolescent seeks confidential healthcare services. Additionally, this response does not address the adolescent's question about contraception.

B. While a doctor can provide guidance on contraception, it's essential for the nurse to engage with the adolescent and assess her needs and preferences before referring her to a healthcare provider.

C. "Before I can help you with that question, I need to know more about your sexual activity" is an appropriate response because it acknowledges the importance of gathering relevant information about the adolescent's sexual activity, preferences, and potential risk factors before providing personalized contraception counseling.

D. This response may come across as judgmental and dismissive of the adolescent's concerns, and it does not address the need for tailored contraception counseling based on individual circumstances.

Question 9: View A nurse is reinforcing teaching with a client who is at 6 weeks of gestation. The client tells the nurse that she smokes one pack of cigarettes per day. The nurse should instruct the client that her newborn is at increased risk for which of the following clinical manifestations?

A. Craniofacial abnormalities B. Hyperactivity C. Hypersensitivity to noise D. Low birth weight

Explanation

Rationale:

A. Craniofacial abnormalities are not typically associated with maternal smoking during pregnancy.

B. Hyperactivity is more commonly associated with prenatal exposure to substances like alcohol or certain medications, rather than maternal smoking.

C. Hypersensitivity to noise is not a typical manifestation of maternal smoking during pregnancy.

D. Low birth weight is a well-established risk associated with maternal smoking during pregnancy. Cigarette smoke contains numerous harmful chemicals that can restrict fetal oxygen supply and impair fetal growth, leading to low birth weight.

Question 10: View A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?

A. When she does not desire future pregnancies B. Prior to discharge from the hospital after giving birth C. Two weeks before attempting pregnancy again D. Prior to giving birth

Explanation

Rationale:

A. Administering the MMR vaccine when the client does not desire future pregnancies may be appropriate for non-pregnant individuals, but it is contraindicated during pregnancy due to the risk of fetal harm.

B. Prior to discharge from the hospital after giving birth is the recommended timing for administering the MMR vaccine to women who are not immune to rubella and who have just given birth. This timing avoids the risk of administering live vaccines during pregnancy while providing protection for future pregnancies.

C. Administering the MMR vaccine two weeks before attempting pregnancy again is not recommended during pregnancy due to the potential risk to the fetus from live vaccines.

D. Administering the MMR vaccine prior to giving birth is not recommended during pregnancy due to the risk of fetal harm.

LPN Maternal Newborn Exam