ATI MATERNAL NEWBORN PROCTORED EXAM WITH RATIONALES Version 1&2

ATI MATERNAL NEWBORN PROCTORED EXAM WITH RATIONALES 2019-2022 Version 1&2 ATI MATERNAL NEWBORN PROCTORED 2019-2022 VERSION 1&2 2019 VERSION 1 [70 QUE+ANS] 2020 [17 QUESTIONS+ANSWERS WITH 4 MULTIPLE CHOICES] 2021 VERSION 2 [70 QUE+ANS] WITH 4 MULTIPLE CHOICES 2022 ATI Proctored Exam Maternal Newborn With rationales [70 Que+Ans] ATI MATERNAL NEWBORN PROCTORED 2019 [70 Que+Ans] Version 1 1. A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff nurses to report to the provider? 2. A nurse is assisting the provider to administer a dinoprostone insertlabor for a client. Which of the following actions should the nurse take? 3. A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work. Which of the following information should the nurse include in the teaching? 4. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take? 5. A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client indicates an understanding of the teaching? 6. A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take? 7. A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? 8. A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statements by the client requires immediate intervention by the nurse? 9. A nurse is providing teaching about expected changes during pregnancyto a client who is at 24 weeks of gestation. Which of the following information should the nurse include? D. "You should expect your uterus to double in size." 10. A nurse is assessing a preterm newborn who is at 32 weeks ofgestation. Which of the following findings should the nurse expect? 11. A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection? D. Meconium-stained fluid 12. A nurse in a provider's office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use the Nagele's rule to calculate the estimated date of delivery. (use the MMDD format with four numerals and no spaces or punctuation.) 1215 13. A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? 14. A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM every 12-hr. Available is dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use as trailing zero.) 0.6 15. A nurse is caring for a client who is in labor and requestnonpharmacological pain management. Which of the following nursing actions promotes client comfort? 16. A nurse is performing an initial assessment of a newborn who wasdelivered with a nuchal cord. Which of the following clinical findings should the nurse expect? A. Facial petechiae 17. A nurse is caring for a client who is receiving prenatal care and is at her 24- week appointment. Which of the following laboratory tests should the nurse plan to conduct? 18. A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? 19. A nurse is reviewing laboratory results for a client who is pregnant.The nurse should expect which of the following laboratory values to increase? B. Fasting blood glucose 20. A nurse is teaching about clomiphene citrate to a client who isexperiencing infertility. Which of the following adverse effects should the nurse include? 21. A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks of gestation and request an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make? 22. A nurse in women's health clinic is obtaining a health history from a client. Which of the following findings should the identify as increasing the client'srisk for developing pelvic inflammatory disease (PID)? 23. A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect? A. Uterine tenderness 24. A nurse is assessing a newborn who was born postterm. Which ofthe following findings should the nurse expect? 25. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? A. Hemorrhage 26. A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method? C. Facial palsy 28. A nurse on the labor and delivery unit is assessing four clients. Which ofthe following clients is a candidate for an indication of labor with misoprostol? B. A client who has gestational diabetes mellitus 29. A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching? B. "Ovulation will remain the same." 30. A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene? 31. A nurse manager on thelabor and delivery unit is teaching a group ofnewly licensed nurses about maternal cytomegalovirus. Which of thefollowing information should thenurse manager include in theteaching? 32. A nurse is assessing a newborn following a forceps assisted birth. Which of thefollowing clinical manifestations should thenurse identify as a complication of thebirth method? C. Facial Palsy 33. A nurse is caring for a client who has hyperemesis gravidarum. Which of thefollowing laboratory tests should thenurse anticipate? Urine Ketones 34. A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of thefollowing findings should thenurse expect? 35. A nurse is caring for a client who is 14 weeks of gestation. At which thefollowing locations should thenurse place theDoppler device whenassessing thefetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above thesymphysis pubis 36. .A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of thefollowing findings should thenurse report to theprovider? 37. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of thefollowing interventions should thenurse include in theplan of care. 38. A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. thenewborn's mother has type 2diabetes mellitus. Which of thefollowing actions should thenurse take? 39. A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. theclient asks thenurse which foods she should eat to ensure adequate calcium intake. thenurse should instruct theclient that which of thefollowing foods has thehighest amount of calcium? 40. A nurse is caring for a client who is in thesecond stage of labor. Which of thefollowing manifestations should thenurse expect? D. The client delivers thenewborn Platelet Count 60.000/ mm3 41. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of thefollowing interventions should thenurse include in theplan? Increase theinfusion rate every 30 to 60 min. 42. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of thefollowing actions should thenurse thenurse takes? (Click on the"Exhibit" Button for additional information about thenewborn. There are three tabs that contain separate categories of date.) 43. A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of thefetal heart rate on themonitor Tracing. Which of thefollowing action should thenurse take? 44. A nurse is planning care for a client who is pregnant and has HIV. Which of thefollowing actions should thenurse include in theplan of care? 45. A nurse is preparing to administer methylergonovine 0.2 mg orally to aclient who is 2 hr postpartum and has a boggy uterus. For which of thefollowing assessment findings should thenurse withhold themedication? 46. A nurse is caring for four clients. For which of thefollowing clients should thenurse auscultate thefetal heart rate during theprenatal visit? 47. A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which of thefollowing results require intervention by thenurse? 48. A nurse is assessing a client following an amniocentesis. Which of thefollowing findings should thenurse recognize as complications? ( select all that apply). A. Amnionitis D. Leakage of amniotic fluid E. Preterm labor 49. A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures? 50. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy . This of the following statements by the client indicates an understanding of the teaching. 51. A nurse is caring for four newborns. Which of the following newborns should the nurse assess first? 52. A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take? 53. A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider? 54. A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take? 55. A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include inthe plan? 56. A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make? A. "You can bathe and dress your baby if you'd like to." 57. A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make? A. "you will need to stay ina side-lying position for 30 minutes after each dose." 58. A nurse is reviewing signs of effective breathing with a client who is 5 days postpartum. Which of the following information should the nurse include inthe teaching? A. "You should feel a tugging sensation when the baby is sucking. 59. A nurse is teaching a client who is at 41 weeks of gestation about a non stress test. Which of the following information should the nurse include inthe teaching? 60. A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider? D. urine output less than 20 61. A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the followingactions should the nurse take? B. Apply counter pressure to the client sacral. 62. A nurse is caring for newborn immediately following birth and notes alarge amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the streps into the box on the placing them in the selected order of performance. Use all the streps.) Compress the bulb syringe Place the bulb syringe in the newborn's mouth. Use the bulb syringe to suction the newborn's nose. Assess the newborn for reflex bradycardia. 63. A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as havingthe lowest incidence of GDM? 64. A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? you shoud anticipate nasal stiffness 65. A nurse is caring for a client who is receiving an epidural block with anopioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication? A. Hypnosis 66. A nurse is caring for a client who is receiving prenatal care and is at her 24- week appointment. Which of the following laboratory tests should the nurse plans to conduct? 67. A nurse is caring for a client who has bacterial vaginosis. Which of the following medication should the nurse expect to administer? A. Metronidale 68. A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? 69. A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the followinginformation should the nurse include? 70. A nurse is caring for client who is in active labor. Following epidural placement the nurse a maternal blood pressure of 98/58 mmHg and minimal FHR variability on the fetal monitor. Which of the following images indicates the action the nurse should take? B. These are the signs of complication of epidural anesthesia as Hypotension, patient need to be connected with Oxygen immediately, rush IV fluids, check for bleeding status and the progress of labor. RN ATI MATERNAL NEWBORN PROCTORED EXAM 2020 1. A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes three contractions in 10 min with late decelerations occurring with two of the contractions. Which of the following findings should the nurse report to the provider a. Reactive b. Nonreactive c. Positive- Indicates an adverse reaction by the fetus and should be reported to the provider d. Negative 2. A nurse is providing family planning education to a client who has decided to use a diaphragm. Which of the following should the nurse include in the plan of care? a. You should replace the diaphragm every 3 years b. You should leave the diaphragm in place for at least 6 hours after intercourse c. You should use an oil based product as a lubricant when inserting the diaphragm d. You should insert he diaphragm when your bladder is full 3. A nurse is providing discharge teaching to a client who is postpartum about resuming sexual activity. Which of the following instructions should the nurse include in the teaching? a. You should use a water soluble gel for lubrication- This will prevent discomfort b. You can resume sexual activity in 10 days c. Your physical reaction to sexual stimulation ill not be altered d. You will not ovulate for 3 months after delivery 4. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta- Cocaines increases the risk for vasoconstriction and possible abruption placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia 5. A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? a. I should eat to taste instead of trying to balance my meals- Eat to taste to avoid nausea b. I will avoid having a snack at bedtime c. I will have 8 oz of hot tea with each meal d. I should pair my sweets with a starch instead of eating them alone 6. A nurse is caring for a client who is in active labor and reports back pain. The nurse performs a vaginal exam and determines the client is 8cm dilated, 100% effaced, and -2 station. The fetus is in the occiput posterior position. Which of the following is an appropriate intervention? a. Perform effleurage during contractions b. Place the client in lithotomy position c. Assist the client to the hands and knees position- Helps relieve back pain and help the fetus rotate d. Apply a fetal scalp electrode 7. A nurse is assessing a client during a weekly prenatal visit that is at 38 weeks of gestation. Which of the following client findings should the nurse report to the provider? a. Blood pressure 136/88 b. Report of insomnia c. Weight gain of 2.2 kg- Above the expected reference range and could indicate complications d. Report of Braxton-Hicks contractions 8. A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client having a seizure. After turning the client’s head to one side, which of the following actions should the nurse take next? a. Monitor the fetal heart rate b. Assess uterine activity c. Administer oxygen via a non-breather mask d. Start a bolus of IV fluids 9. A nurse is providing discharge instructions to a client who had a vaginal delivery and is breastfeeding her newborn. Which of the following statements indicates an understanding of the teaching? a. I will need to eat an additional 330 calories a day while I’m breastfeeding- b. I will change my perineal pad at least twice a day c. I will massage my uterus daily for 7 days d. I will breastfeed my baby every 2 hours 10. A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. Assessment of dilation and effacement b. Leopold maneuvers- helps the nurse assess the position of the fetus to best determine the optimal placement for the fetal monitoring transducer. c. Sterile speculum exam d. Nitrazine test 11. A client who is pregnant presents to a prenatal clinic for her first visit. She tells the nurse that her last normal menstrual period began Oct 13. Using Nagele’s rule, the nurse should determine the client’s estimated date of delivery as which of the following? a. July 6 b. July 13 c. July 20- Add a year, subtract 3 months, add 7 days d. July 27 12. A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes three contractions in 10 min with late decelerations occurring with two of the contractions. Which of the following findings should the nurse report to the provider a. Reactive b. Nonreactive c. Positive- Indicates an adverse reaction by the fetus and should be reported to the provider d. Negative 13. A nurse is providing family planning education to a client who has decided to use a diaphragm. Which of the following should the nurse include in the plan of care? a. You should replace the diaphragm every 3 years b. You should leave the diaphragm in place for at least 6 hours after intercourse c. You should use an oil based product as a lubricant when inserting the diaphragm d. You should insert he diaphragm when your bladder is full 14. A nurse is providing discharge teaching to a client who is postpartum about resuming sexual activity. Which of the following instructions should the nurse include in the teaching? a. You should use a water soluble gel for lubrication- This will prevent discomfort b. You can resume sexual activity in 10 days c. Your physical reaction to sexual stimulation ill not be altered d. You will not ovulate for 3 months after delivery 15. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta- Cocaines increases the risk for vasoconstriction and possible abruption placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia 16. A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? a. I should eat to taste instead of trying to balance my meals- Eat to taste to avoid nausea b. I will avoid having a snack at bedtime c. I will have 8 oz of hot tea with each meal d. I should pair my sweets with a starch instead of eating them alone 17. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Warm the heel prior to the puncture b. Request a prescription for IM analgesic c. Use a manual lance blade to pierce the skin d. Swaddle the newborn after the heel puncture- Effective technique to diminish the pain experience for the newborn. ATI Maternal newborn 2021 with 4 multiple choices Version 2 1. A nurse is assessing a newborn following a forceps assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method? A. Hypoglycemia B. Polycythemia C. Facial Palsy D. Bronchopulmonary dysplasia 2. A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statement by client indicates an understanding of the teaching? A. “The medication could cause me to experience heart palpitation” B. “This medication could cause me to experience blurred vision” C. “This medication could cause me to experience ringing in my ears” D. “This medication could cause me to experience frequent …” 4. A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate? A. Urine Ketones B. Rapid plasma regain C. Prothrombin time D. Urine culture 5. A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort? A. Assisting the client into squatting position B. Having the client lie in a supine position C. Applying fundal pressure during contractions D. Encouraging the client to void every 6 hr 6. A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect? A. Thick, White Vaginal Discharge B. Urinary Frequency C. Vulva Lesions D. Malodorous Discharge 7. A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above the umbilicus D. Lateral at the Xiphoid Process 8. Nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? A. Urine protein concentration 200 mg/ 24 hr B. Creatnine 0.8 mg/ dL C. Hemoglobin 14.8 g/ dL D. Platelet Count 60.000/ mm3 9. A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include? A. Tinnitus B. Urinary Frequency C. Breast Tenderness D. Chills 10. A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect? A. Bulging Fontanels B. Nasal Flaring C. Length from head to heel of 40 cm (15.7 in) D. Chest circumference 2 cm (0.8 in) smaller than the head circumference 11. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care. A. Increase the newborn’s visual stimulation B. Weigh the newborn every other day C. Discourage parental interaction until after a social evaluation D. Swaddle the newborn in a flexed position 12. A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take? A. Obtain a blood sample for a serum glucose level B. Feed the newborn immediately C. Administer 50 mL of dextrose solution IV D. Reassess the blood glucose level prior to the next feeding 13. A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply). A. “I will limit my time in the hot tub to 30 minutes after exercise.” B. “I should consume three 8-ounce glasses of water after I exercise.” C. “I will check my heart rate every 15 minutes during exercise sessions.” D. “I should limit exercise sessions to 30 minutes when the weather is humid.” E. “I should rest by lying on my side for 10 minutes following exercise.” 14. A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider? A. Contraction durations of 95 to 100 seconds B. Contraction frequency of 2 to 3 min apart C. Absent early deceleration of fetal heart rate D. Fetal heart rate is 140/min 15. A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)? A. Recurrent Cystitis B. Frequent Alcohol Use C. Use of Oral Contraceptives D. Chlamydia Infection 16. A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching? A. Hepatitis B B. Rotavirus C. Pneumococcal D. Varicella 17. A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. ½ cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli 18. A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Nagele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.) December 15 1215 19. A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? A. The client expels the placenta B. The client experiences gradual dilation of the cervix C. The client begins have regular contractions. D. The client delivers the newborn 20. A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. “It burns when I urinate B. “My feet are really swollen today”. C. “I didn’t have lunch today, but I had breakfast this morning”. D. “I have been seeing spot this morning” 21. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. “I should position my baby’s car seat at a 45-degree angle in the car.” B. “I should place the car seat rear facing until my baby is 12 months old.” C. “I should place the harness snugly in a slot above my baby’s shoulders.” D. “I should position the retainer clip at the top of my baby’s abdomen.” 22. A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hermolytic disease? A. The mother is Rh positive, and the father is Rh negative B. The mother is Rh negative, and the father is Rh positive C. The mother and the father are both Rh positive D. The mother and the father are both Rh negative 23. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has diabetes mellitus and an HbA1c of 5.8% B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36% 24. A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene? A. Molding B. Vernix Caseosa C. Acrocyanosis D. Sternal retractions 25. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider? A. A client who has a urinary output of 300 ml in 8 hr B. A client who reports abdominal cramping during breastfeeding C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes D. A client who reports lochia rubra requiring changing perineal pads every 3 hr 26. A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer? A. Metronidazole B. Penicillin C. Acyclovir D. Gentamicin 27. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? A. Hyperemesis B. Proteinuria C. Hypoxia D. Hemorrhage 28. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? A. Increase the infusion rate every 30 to 60 min. B. Maintain the client in a supine position. C. Titrate the infusion rate by 4 milliunits/min. D. Limit IV intake to 4 L per 24 hr. 29. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the “Exhibit” Button for additional information about the newborn. There are three tabs that contain separate categories of date.) A. Administer nitric oxide inhalation therapy to the newborn B. Insert an orogastric decompression tube with low wall suction. C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Measure the abdominal circumference at the level of the newborn’s umbilicus every 2 hr. 30. A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take? A. Decrease maintenance IV solution infusion rate. B. Place the client in lateral position. C. Administer misoprostol 25 mcg vaginally D. Administer oxygen via face mask at 2 L/min 31. A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care? A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation. B. Use a fetal scalp electrode during labor and delivery. C. Administer a pneumococcal immunization to the newborn within 4 hr following birth. D. Bathe the newborn before initiating skin-to-skin contact 32. A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? A. Blood pressure 142/92 mm Hg B. Urine output 100 mL in hr C. Pulse 58/min D. Respiratory rate 14/min 33. A nurse is reviewing laboratory results for client who is pregnant. The Nurse should expect which of the following laboratory values to increase? A. RBC count B. Bilirubin C. Fasting blood glucose D. Bun 34. A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM 12 hr. Available in dexamethasome 10 mg/mL. How mane mL of dexamethasome should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.) .6mL 35. A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit? A. A client who has an ultrasound that confirms a molar pregnancy B. A client who has a crown-rump length of 7 weeks gestation C. A client who has a positive urine pregnancy test 1 week after missed menses D. A client who has felt quickening for the first time 36. A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Dress the newborn in lightweight clothing. B. Avoid using lotion or ointment on the newborn skin. C. Keep the newborn supine throughout treatment D. Measure the newborn’s temperature every 8hr 37. A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which of the following results require intervention by the nurse? A. WBC count 10,000/mm3 B. Platelets 180,000/mm3 C. Hemoglobin 20g/dL D. Glucose 20 mg/dL 38. A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (select all that apply). A. Amnionitis B. Urinary tract infection C. Polyhydramnios D. Leakage of amniotic fluid E. Preterm labor 39. A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures? A. Assisting a mother with breastfeeding B. Performing a newborn’s initial bath C. Administering the measles, mumps, rubella vaccine D. Performing umbilical cord care 40. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2 months of pregnancy. This of the following statements by the client indicates an understanding of the teaching. A. “I will count baby’s lacks every other day. B. “I will alternate the arm use to check my blood pressure. C. I will consume 50 grams of protein daily 41. A nurse is caring for four newborns. Which of the following newborns should the nurse assess first? A. newborn who has nasal flaring B. newborn who has subconjunctival hemorrhage of the left eye C. A newborn who has overlapping suture lines D. A newborn who has not rust-stained urine 42. A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection. A. Meconium – start fluid B. placenta previa C. Midline episiotomy D. Gestational hypertension 43. A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Administer indomethacin B. Insert a second using a 22-gauge IV catheter, C. Insert an indwelling urinary catheter. D. Administer oxygen at 4L/min via nasal cannula. 44. A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth. A. Pneumococcal B. Hepatitis C. Human papillomavirus D. Rubella 45. A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider? A. Hgb 20 g/dL B. Bilirubin 2mg/dL C. Platelets 200 .000/mm3 D. WBC count 32.000/mm3 46. A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take? A. Give the newborn a warm bath. B. Apply a cap to the newborn head. C. Reposition the newborn. D. Obtain an oxygen saturation level 47. A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Apply a thin layer of lotion to the newborn skin every 8 hrs. B. Give the newborn 1oz of glucose water every 4 hrs C. Ensure the newborn eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy 48. A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make? A. “You can bathe and dress your baby if you’d like to.” B. “If you don’t hold the baby it will make letting go much harder.” C. “You should name the baby so she can have an identity.” D. “I’m sure you will be able to have another baby when you’re ready.” 49. A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make? A. “you will need to stay in a side-lying position for 30 minutes after each dose.” B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.” C. ” You will receive a magnesium supplement immediately following therapy.” D. ” You will need to have a full bladder before the therapy begins.” 50. A nurse is assessing a newborn who was born Postterm. Which of the following findings should the nurse expect? A. Nails extending over tips of fingers B. Large deposits of subcutaneous fat C. Pale, translucent skin D. Thin covering of fine hair on shoulders and back 51. A nurse is planning to teach a group of clients who are about breastfeeding after returning to work .Which of the following infection should the nurse include in the teaching? A. “Thawed breast milk can be refrigerated for up to 72 hours.” B. “Breast milk can be stored in a deep freezer for 12 months.” C. Breast milk can be stored at room temperature for up to 12 hours.” D. “Thawed breast milk that is unused can be refrozen.” 52. A nurse is assessing a newborn who was born Postterm. Which of the following findings should the nurse expect? A. An Rh negative mother who has an Rh- positive infant B. An Rh –positive mother who has an Rh- negative infant C. An Rh-positive mother who has an Rh- positive infant D. An Rh- negative mother who has an Rh- negative infant 53. A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Provide a stimulating environment B. Monitor blood glucose level every hr. C. Initiate seizure precautions. D. Place the infants on his back with legs extended. 54. A nurse is reviewing signs of effective breathing with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching? A. “You should feel a tugging sensation when the baby is sucking. B. You should expect your baby to have two to three wet diapers in 24hour period C. “Your baby’s urine should appear dark and concentrated”. D. “Your breast should stay firm after the baby breastfeeds”. 55. A nurse is teaching a client who is at 41 weeks of gestation about a non stress test. Which of the following information should the nurse include in the teaching? A. “This test will confirm fetal lung maturity “. B. “This test will determine adequacy of placental perfusion”. C. “This test will detect fetal infection”. D. “This test will predict maternal readiness for labor”. 56. A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol? A. A client who has active genital herpes B. A client who has gestational diabetes mellitus C. A client who has a previous uterine incision D. A client who has placenta previa 57. A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider? A. Blood pressure 148/94mm Hg B. Respiratory rate 14mm C. Urinary output 20 mL/hr D. 2+deep tendon reflexes 58. A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Instruct the client to use effleurage B. Apply counter pressure to the client sacral. C. Assist the client with patterned-paced breathing. D. Teach the client the technique of biofeedback. 59. A nurse is caring for newborn immediately following birth and notes a large amount of mucus in the newborn’s mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the streps into the box on the placing them in the selected order of performance. Use all the streps.) A. Assess the newborn for reflex bradycardia. B. Compress the bulb syringe C. Place the bulb syringe in the newborn’s mouth. D. Use the bulb syringe to suction the newborn’s nose. 1. Compress the bulb syringe 2. Place the bulb syringe in the newborn’s mouth. 3. Use the bulb syringe to suction the newborn’s nose. 4. Assess the newborn for reflex bradycardia. 60. A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as having the lowest incidence of GDM? A. Asian B. Non-Hispanic White American C. Hispanic D. African American 61. A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. “It burns when I urinate B. “My feet are really swollen today”. C. “I didn’t have lunch today, but I have breakfast this morning”. D. “I have been seeing spot this morning” 62. A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? A. “Your stomach will empty rapidly” B. “You should expect your uterus to double in size” C. “You should anticipate nasal stuffiness.” D. “Your nipples will become lighter in color”. 63. A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? A. “your contraction will become more intense when walking” B. “you will have dilation and effacement of the cervix” C. You will have bloody show” D. “Your contraction will become temporally regular” 64. A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication? A. Hypnosis B. Polyuria C. Bilateral crackles A. Hyperglycemia 65. A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of thefollowing laboratory tests should thenurse plans to conduct? A. Group B strep culture B. 1-hr glucose tolerance test C. Rubella titer D. Blood type and Rh 66. A nurse is caring for a client who has bacterial vaginosis. Which of thefollowing medication should thenurse expect to administer? A. Metronidale B. Fluconazole C. Acyclovir lOMoARcPSD|11700591 67. A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of thefollowingactions should thenurse take? A. Place a snug dressing on theclient’s nipple when not breastfeeding. B. Ensure thenewborn’s mouth is wide open before latching to thebreast. C. Encourage theclient to limit thenewborn’s feeding to 10 min on each breast. D. Instruct theclient to begin thefeeding with thenipple that is most tender. 68. A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of thefollowing finding shouldthe nurse expect? A. Minimal arm recoil B. Popliteal angle of less than 90 C. Creases over theentire sole D. Sparse lanugo 69. A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control laborpain. Which of thefollowing information should thenurse include? A. Focusing on controlling body functions B. “Synchronized breathing will be required during hypnosis” C. “Hypnosis can be beneficial in you practiced it during theprenatal period” D. “Hypnosis does not work for controlling pain associated with labor”. 70. A nurse is caring for client who is in active labor. Following epidural placement thenurse a maternal blood pressure of 98/58 mmHg and minimal FHR variability on thefetal monitor. Which of thefollowing images indicatesthe action thenurse should take? • These are thesigns of complication of epidural anesthesia as Hypotension, patient need to be connected with Oxygen immediately, rush IV fluids, check for bleeding status and theprogress of labor. 2022 ATI Proctored Exam Maternal Newborn 1. A nurse is providing discharge teaching to a client following tubal ligation (occlusion). Which of thefollowing statement by theclient indicates an understanding of theteaching? A. “premenstrual tension will no longer be present.” B. “Ovulation will remain thesame.” C. “Hormone replacements will be needed following this procedure.” D. “My monthly menstrual period will be shorter.” ANS: Ovulation (egg release from theovaries) will remain thesame. Tubal ligation also known as having your lOMoARcPSD|11700591 tubes tied or tubal sterilization is a type of permanent birth control. During tubal ligation, thefallopian tubes are cut, tied or blocked to permanently prevent pregnancy. Tubal ligation prevents an egg from traveling from theovaries through thefallopian tubes and blocks sperm from traveling up thefallopian tubes to theegg. theprocedure doesn't affect your menstrual cycle it just prevents fertilization. 2. A nurse is assessing a newborn following forceps-assisted birth. Which of thefollowing clinical manifestations should thenurse identify as a complication of thebirth method? A. Hypoglycemia B. Polycythemia C. Facial Palsy D. Bronchopulmonary dysplasia lOMoARcPSD|11700591 ANS: Difficult delivery, with or without theuse of an instrument called forceps, may lead to facial palsy. Facial paralysis 15 minutes after forceps birth or absence of movement on affected side is especially noticeable when infant cries. 3. A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of thefollowing statements by theclient indicates understanding of theteaching? A. “This medication could cause me to experience heart palpitations.” B. “This medication could cause me to experience blurred vision.” C. “This medication could cause me to experience ringing in my ears.” D. “This medication could cause me to experience frequent urination.” ANS: Beta-adrenergic agents such as terbutaline (Brethine) are associated with various side effects, including tachycardia, irregular pulse, myocardial ischemia, and pulmonary edema. Therefore, these medications should not be used in women with known or suspected heart Disease. 4. A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of thefollowing nursing actions promotes client comfort? A. Assisting theclient into squatting position B. Having theclient lie in a supine position C. Applying fundal pressure during contractions D. Encouraging theclient to void every 6 hrs. lOMoARcPSD|11700591 5. A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of thefollowing findings should thenurse expect? A. Thick, White Vaginal Discharge B. Urinary Frequency C. Vulva Lesions D. Malodorous Discharge ANS: Although trichomoniasis may be asymptomatic, women commonly experience characteristically yellowish-to-greenish, frothy, mucopurulent, copious, malodorous discharge. Inflammation of thevulva, vagina, or both may be present; and thewoman may complain of irritation and pruritus. Dysuria and dyspareunia are often present. 6. A nurse is caring for a client who is at 14 weeks of gestation. At which of thefollowing locations should thenurse place thedoppler device when assessing thefetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above thesymphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above theumbilicus D. Lateral at theXiphoid Process ANS: Toward theend of thefirst trimester, before theuterus is an abdominal organ, thefetal heart tones (FHTs) can be heard with an ultrasound fetoscope or an ultrasound stethoscope To hear theFHTs, place theinstrument in themidline just above thesymphysis pubis and lOMoARcPSD|11700591 apply firm pressure. thewoman and her family should be offered theopportunity to listen to theFHTs. thehealth status of thefetus is assessed at each visit for theremainder of thepregnancy. 7. A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of thefollowing findings should thenurse report to theprovider? A. Urine protein concentration 200 mg/24 hr. B. Creatinine 0.8 mg/ dL C. Hemoglobin 14.8 g/ dL D. Platelet Count 60,000/ mm3 ANS: Platelets < 100,000/mm3 (60,000/mm3) is below theexpected reference range, which can indicate DIC. thenurse should report this result to theprovider. In a 24-hour specimen proteinuria is defined as a concentration at or > 300 mg/24 hours. 8. A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of thefollowing adverse effect should thenurse include? A. Tinnitus B. Urinary Frequency C. Breast Tenderness D. Chills 9. A nurse is assessing a newborn upon admission to thenursery. Which of thefollowing should thenurse expect? A. Bulging Fontanels lOMoARcPSD|11700591 B. Nasal Flaring C. Length from head to heel of 40 cm (15.7 in) D. Chest circumference 2 cm (0.8 in) smaller than thehead circumference ANS: Measure at nipple line 2-3 cm (0.8-1.2 in) less than head circumference; average 30-33 cm (11.8-13 in) ≤ 30 cm. 10. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of thefollowing interventions should thenurse include in theplan of care? A. Increase thenewborn’s visual stimulation B. Weigh thenewborn every other day C. Discourage parental interaction until after a social evaluation D. Swaddle thenewborn in a flexed position ANS: Swaddling in a flexed position with hands midline against chest and legs loosely swaddled in lumbar flexion to decrease sensory stimulation. Minimize environmental and physical stimulation low lighting and noise level do not use TV or mobiles. Avoidance of abrupt changes in infant’s environment handle gently and close to thebody to increase sense of 11. A nurse is caring for a newborn who is 6 hrs. old and has a bedside glucometer reading of 65 mg/dL. thenewborn’s mother has type 2 diabetes mellitus. Which of thefollowing actions should thenurse take? A. Obtain a blood sample for a serum glucose level B. Feed thenewborn immediately lOMoARcPSD|11700591 C. Administer 50 mL of dextrose solution IV D. Reassess theblood glucose level prior to thenext feeding. ANS: When babies are just 1 hour to 2 hours old, thenormal level is just under 2 mmol/L (36 mg/dL), but it will rise to adult levels (over 3 mmol/L or 54 mg/dL) within two to three days. In babies who need treatment for low blood glucose or are at risk for low blood glucose, a level over 2.5 mmol/L (45 mg/dL) is preferred. 12. A nurse is providing teaching to a client about exercise safety during pregnancy. Which of thefollowing statements by theclient indicates an understanding of theteaching? (Select all that apply). A. “I will limit my time in thehot tub to 30 minutes after exercise.” B. “I should consume three 8-ounce glasses of water after I exercise.” C. “I will check my heart rate every 15 minutes during exercise sessions.” D. “I should limit exercise sessions to 30 minutes when theweather is humid.” E. “I should rest by lying on my side for 10 minutes following exercise.” ANS: , C, E 13. A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of thefollowing findings should thecharge nurse instruct thestaff members to report to theprovider? A. Contraction durations of 95 to 100 seconds B. Contraction frequency of 2 to 3 min apart C. Absent early deceleration of fetal heart rate lOMoARcPSD|11700591 D. Fetal heart rate is 140/min ANS: For a normal uterine activity during labor contraction duration remains fairly stable throughout first and second stages, ranging from 45-80 seconds, not generally exceeding 90 seconds. 14. A nurse in a woman’s health clinic is obtaining a health history from a client. Which of thefollowing findings should thenurse identify as increasing theclient’s risk for developing pelvic inflammatory disease (PID)? A. Recurrent Cystitis B. Frequent Alcohol Use C. Use of Oral Contraceptives D. Chlamydia Infection ANS: Pelvic inflammatory disease is an infection of a woman's reproductive organs. It is a complication often caused by some STDs, like chlamydia and gonorrhea. Other infections that are not sexually transmitted can also cause PID. 15. A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of thefollowing immunizations should thenurse include in theteaching? A. Hepatitis B B. Rotavirus C. Pneumococcal lOMoARcPSD|11700591 D. Varicella ANS: Hepatitis B immunization is recommended at birth, 1 to 2 months, and between 6 to 18 months. It is injected intramuscularly soon after birth. For newborns born to hepatitis- infected mothers, hepatitis B immune globin (HBIG) also should be administered within 12 hrs. of birth. thevastus lateralis is thepreferred site of intramuscular injections in newborns, and no more than 0.5 mL should be administered in one injection. Shortly after birth, your baby should receive thefirst dose of thevaccine to help protect against thefollowing disease: Hepatitis B and 1-month later RV, DTap, Hib, PCV13, & IPV. 16. A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. theclient asks thenurse which foods she should eat to ensure adequate calcium intake. thenurse should instruct theclient that which of thefollowing foods has thehighest amount of calcium? A. ½ cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli ANS: ½ cup cubed avocado contains 9 mg of calcium. 1 large banana contains 7 mg of calcium. 1 medium potato 26 mg of calcium. 1 cup cooked broccoli contains 180 mg of calcium. 17. A nurse in a provider’s office is assessing a client at her first antepartum visit. theclient lOMoARcPSD|11700591 states that thefirst day of her last menstrual period was March 8. Use Nagele’s rule to calculate theestimated date of delivery. (Use theMMDD format with four numerals and no spaces or punctuation.) ANS: March 8 – 3 months = December 8 + 7 = Dec. 13 because of Feb. having 29 days. 18. A nurse is caring for a client who is in thesecond stage of labor. Which of thefollowing manifestations should thenurse expect? A. The client expels theplacenta. B. The client experiences gradual dilation of thecervix C. The client begins to have regular contractions. D. The client delivers thenewborn. ANS: The second stage of labor lasts from thetime thecervix is fully dilated to thebirth of thefetus. 19. A nurse is assessing a client who is at 37 weeks (about 8 and a half months) of gestation. Which of thefollowing statement by theclient requires immediate intervention by thenurse? A. “It burns when I urinate.” B. “My feet are really swollen today.” C. “I didn’t have lunch today, but I have breakfasted this morning.” D. “I have been seeing spot this morning.” ANS: During pregnancy, you are more susceptible to urinary tract infections. Most commonly, such lOMoARcPSD|11700591 infections are confined to thebladder, when they are known as cystitis. Symptoms of cystitis include a frequent, urgent need to urinate and a painful burning sensation when passing urine; there may be some blood in your urine. 20. A nurse is providing discharge teaching to a new parent about car seat safety. Which of thefollowing statements by theparent indicates an understanding of theteaching? A. “I should position my baby’s car seat at a 45-degree angle in thecar.” B. “I should place thecar seat rear facing until my baby is 12 months old.” C. “I should place theharness snugly in a slot above my baby’s shoulders.” D. “I should position theretainer clip at thetop of my baby’s abdomen.” ANS: Set theseat at a 45-degree angle. Your baby's head should rest at least 2 inches below thetop of thecar seat. 21. A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of thefollowing genetic information should the nurse include in theprogram as a cause of hemolytic disease? A. The mother is Rh positive, and thefather is Rh negative. B. The mother is Rh negative, and thefather is Rh positive. C. The mother and thefather are both Rh positive. D. The mother and thefather are both Rh negative. lOMoARcPSD|11700591 ANS: Hemolytic Diseases in Newborns (HDN) most frequently occurs when a Rh-negative mother has a baby with a Rh-positive father. When thebaby's Rh factor is positive, like thefather's, problems can develop if thebaby's red blood cells cross to theRh-negative mother. This usually happens at delivery when theplacenta detaches. 22. A nurse on an antepartum unit is reviewing themedical records for four clients. Which of thefollowing clients should thenurse assess first? A. A client who has diabetes mellitus and an HbA1c of 5.8% B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36% ANS: As a consequence of this physiological adaptation, normal pregnancy is associated with reduction in serum sodium of 3-6 mmol/L and reduction in serum osmolality of 10 mOsm/kg. Hyponatremia is diagnosed if serum sodium <135 mmol/L in non-pregnant individuals, but <130 mmol/L in pregnant women. 23. A nurse is assessing a newborn immediately following a vaginal birth. For which of thefollowing findings should thenurse intervene? A. Molding B. Vernix Caseosa C. Acrocyanosis lOMoARcPSD|11700591 D. Sternal retractions ANS: Sternal retraction is a common clinical sign of respiratory distress in premature infants. Frontal chest radiographs show increased, ill-defined central radiolucency over thelower chest which correlates well with a curvilinear indentation seen on lateral views. 24. A nurse on thepostpartum unit is caring for four clients. For which of thefollowing clients should thenurse notify theprovider? A. A client who has a urinary output of 300 ml in 8 hr. B. A client who reports abdominal cramping during breastfeeding C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes. D. A client who reports lochia rubra requiring changing perineal pads every 3 hr. ANS: Symptoms of magnesium sulfate toxicity are seen with thefollowing maternal serum concentrations: loss of deep tendon reflexes (9.6-12 mg/dL) (> 7 mEq/L), respiratory depression (12-18 mg/dL) (> 10 mEq/L), and cardiac arrest (24-30mg/dL) (> 25mEq/L). 25. A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of thefollowing medications should thenurse plan to administer? A. Metronidazole B. Penicillin C. Acyclovir lOMoARcPSD|11700591 D. Gentamicin ANS: Acyclovir is used to treat infections caused by certain types of viruses. It treats cold sores around themouth (caused by herpes simplex), shingles (caused by herpes zoster), and chickenpox. This medication is also used to treat outbreaks of genital herpes. 26. A nurse is caring for a client following an amniocentesis. thenurse should observe theclient for which of thefollowing complications? A. Hyperemesis B. Proteinuria C. Hypoxia D. Hemorrhage ANS: That is why ultrasound scanning has reduced risks previously associated with amniocentesis such as fetomaternal hemorrhage from a pierced placenta. 27. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of thefollowing interventions should thenurse include in theplan? A. Increase theinfusion rate every 30 to 60 min. B. Maintain theclient in a supine position. C. Titrate theinfusion rate by 4 milliunits/min. D. Limit IV intake to 4 L per 24 hr. lOMoARcPSD|11700591 28. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of thefollowing actions should thenurse take? (Click on the“Exhibit” Button for additional information about thenewborn. There are three tabs that contain separate categories of date.) A. Administer nitric oxide inhalation therapy to thenewborn B. Insert an orogastric decompression tube with low wall suction. C. Provide thenewborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Measure theabdominal circumference at thelevel of thenewborn’s umbilicus every 2 hr. ANS: E. coli can cause a severe complication that occurs most commonly in young children (age 5 and younger) called hemolytic uremic syndrome. This condition destroys platelets and red blood cells and leads to kidney failure. 29. A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of thefetal heart rate on themonitor Tracing. Which of thefollowing action should thenurse take? A. Decrease maintenance IV solution infusion rate. B. Place theclient in lateral position. C. Administer misoprostol 25 mcg vaginally D. Administer oxygen via face mask at 2 L/min ANS: lOMoARcPSD|11700591 By laying in theleft lateral recumbent position, theuterus is kept off thematernal inferior vena cava and theright iliac artery. Increasing therate of infusion of themaintenance IV solution is an appropriate action to take when late decelerations occur, not decreasing therate. Oxygen should be administered at a rate of 8 to 10 L/min when late decelerations occur due to uterine hyperstimulation. Though it was not listed in themultiple choice discontinue theoxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation. 30. A nurse is planning care for a client who is pregnant and has HIV. Which of thefollowing actions should thenurse include in theplan of care? A. Instruct theclient to stop taking theantiretroviral medication at 32 weeks of gestation. B. Use a fetal scalp electrode during labor and delivery. C. Administer a pneumococcal immunization to thenewborn within 4 hrs. following birth. D. Bathe thenewborn before initiating skin-to-skin contact ANS: As early in life as possible, HIV-exposed infants and children should receive all vaccines under theExpanded Program for Immunization (EPI), including Haemophilus influenzae type B and pneumococcal vaccine. 31. A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hrs. postpartum and has a boggy uterus. For which of thefollowing assessment findings should thenurse withhold themedication? A. Blood pressure 142/92 mm Hg B. Urine output 100 mL in hr. lOMoARcPSD|11700591 C. Pulse 58/min D. Respiratory rate 14/min ANS: Presence of other medical problems such as HTN contraindicates with methylergonovine. Because methylergonovine is vasoconstrictive, monitor patient's blood pressure, heart rate, and uterine response prior to and during administration. 32. A nurse is reviewing laboratory results for client who is pregnant. theNurse should expect which of thefollowing laboratory values to increase? A. RBC count B. Bilirubin C. Fasting blood glucose D. Bun ANS: RBC count increases from million/mm3 4.2-5.4 to 5-6.25 million/mm3 during pregnancy. 33. A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM 12 hr. Available in dexamethasone 10 mg/mL. How many mL of dexamethasone should thenurse administer per dose? (Round theanswer to thenearest tenth. Use a leading zero if it applies. Do not use trailing zero.) ANS: 0.6 mL 34. A nurse is caring for four clients. For which of thefollowing clients should thenurse auscultate thefetal heart rate during theprenatal visit? A. A client who has an ultrasound that confirms a molar pregnancy B. A client who has a crown-rump length of 7 weeks gestation lOMoARcPSD|11700591 C. A client who has a positive urine pregnancy test 1 week after missed menses D. A client who has felt quickening for thefirst time. ANS: In pregnancy terms, quickening is themoment in pregnancy when thepregnant woman starts to feel or perceive fetal movements in theuterus. 35. A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of thefollowing actions should thenurse include in theplan of care? A. Dress thenewborn in lightweight clothing. B. Avoid using lotion or ointment on thenewborn skin. C. Keep thenewborn supine throughout treatment D. Measure thenewborn’s temperature every 8hr ANS: Frequent skin care is important, but do not use lotions, creams, balms, or ointments on uncovered skin. These products react with thephototherapy lights and cause burns. 36. A nurse is receiving laboratory results for a term newborn who is 24 hrs. old. Which of thefollowing results require intervention by thenurse? A. WBC count 10,000/mm3 B. Platelets 180,000/mm3 C. Hemoglobin 20g/dL D. Glucose 20 mg/dL lOMoARcPSD|11700591 ANS: But at birth, it's common for a newborn to have a blood glucose level as low as 30 mg per dl, which will gradually increase to 54 to 72 mg/dl. According to guidelines from theAmerican But at birth, it's common for a newborn to have a blood glucose level as low as 30 mg per dl, which will gradually increase to 54 to 72 mg/dl. According to guidelines from theAmerican Academy of Pediatrics, thegenerally accepted blood glucose level for treating newborn hypoglycemia is 47 mg/dl. 37. A nurse is assessing a client following an amniocentesis. Which of thefollowing findings should thenurse recognize as complications? (select all that apply). A. Amnionitis B. Urinary tract infection C. Polyhydramnios D. Leakage of amniotic fluid E. Preterm labor ANS: , D, E Amniocentesis is a well-known procedure performed during pregnancy for diagnostic and therapeutic purposes. Typical complications of theprocedure include infection of theamniotic sac, preterm labor, respiratory distress, fetal deformities, trauma, alloimmunization, and failure of thepuncture wound to heal properly. 38. A nurse on a labor and delivery unit is reviewing infection control standards with a newly lOMoARcPSD|11700591 licensed nurse. thenurse should instruct thenewly licensed nurse to don gloves for which of thefollowing procedures? A. Assisting a mother with breastfeeding B. Performing a newborn’s initial bath C. Administering themeasles, mumps, rubella vaccine D. Performing umbilical cord care ANS: Wear gloves when a reasonably anticipated possibility exists that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) might occur. Gloves should be worn during infant eye prophylaxis, care of theumbilical cord, circumcision site, parenteral procedures, diaper changes, contact with colostrum, and postpartum assessments. Wear gloves with fit and durability appropriate to thetask. 39. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during thelast 2 months of pregnancy. Which of thefollowing statements by theclient indicates an understanding of theteaching? A. “I will count baby’s kicks every other day.” B. “I will alternate thearm use to check my blood pressure.” C. “I will check my urine for protein daily.” D. “I will consume 50 grams of protein daily.” ANS: This urine will be tested to see if you are passing more than 300 mg of protein in a day. Any amount of protein in your urine over 300 mg in one day may indicate preeclampsia. lOMoARcPSD|11700591 However, theamount of protein doesn't define how severe thepreeclampsia is or may get. To test your urine protein at home on a daily basis, use a simple test kit containing a urine testing strip that you dip into a fresh sample of your urine. 40. A nurse is caring for four newborns. Which of thefollowing newborns should thenurse assess first? A. newborn who has nasal flaring B. newborn who has subconjunctival hemorrhage of theleft eye C. A newborn who has overlapping suture lines D. A newborn who has not rust-stained urine ANS: Based on theABC rule, respiratory distress needs more attention. Nasal flaring occurs when thenostrils widen while breathing. It is often a sign of trouble breathing. Nasal flaring may be an indication of breathing difficulty, or even respiratory distress in infants. 41. A nurse is reviewing theelectronic medical record of a postpartum client. thenurse should identify that which of thefollowing factors places theclient at risk for infection. A. Meconium-stained fluid B. placenta previa C. Midline episiotomy D. Gestational hypertension ANS: Midline episiotomy puts theclient in risk for infection. lOMoARcPSD|11700591 42. A nurse is caring for a client who is 4 hrs. postpartum and is experiencing hypovolemic shock. Which of thefollowing actions should thenurse take? A. Administer indomethacin orally B. Insert a second IV using a 22-gauge IV catheter, C. Insert an indwelling urinary catheter. D. Administer oxygen at 2 L/min via nasal cannula. ANS: Insert an indwelling urinary catheter to monitor perfusion of kidneys. Provide additional or maintain existing IV infusion of lactated Ringer's solution or normal saline solution to restore circulatory volume (woman should have two patent IV lines; insert second IV infusion using 16- to 18-gauge IV catheter). Give oxygen by nonrebreather face mask or nasal prongs at 8 to 10 L/min. 43. A nurse is teaching a client who is 28 weeks of gestation and not up to date on current immunization. Which of thefollowing immunizations should thenurse inform theclient to anticipate receiving following birth? A. Pneumococcal B. Hepatitis B C. Human papillomavirus D. Rubella ANS: Hepatitis B immunization is recommended at birth, 1 to 2 months, and between 6 to 18 lOMoARcPSD|11700591 months. It is injected intramuscularly soon after birth. 44. A nurse is caring for a newborn who is 24 hrs. old. Which of the following Laboratory findings should the nurse report to the provider? A. Hgb 20 g/dL B. Bilirubin 2mg/dL C. Platelets 200,000/mm3 D. WBC count 32,000/mm3 ANS: An abnormal number of WBCs often indicates that the newborn baby's body is fighting some sort of infection. Results of the CBC can be obtained quite quickly. Blood culture: The blood culture will determine if any bacteria can be grown in the blood. 45. A nurse is caring for newborn who is 1 hr. old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.10C (97F). Which of the following actions should the nurse take? A. Give the newborn a warm bath. B. Apply a cap to the newborn head. C. Reposition the newborn. D. Obtain an oxygen saturation level ANS: A cap may be worn to decrease heat loss from the infant's head. lOMoARcPSD|11700591 46. A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Apply a thin layer of lotion to the newborn skin every 8 hrs. B. Give the newborn 1oz of glucose water every 4 hrs. C. Ensure the newborn eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy ANS: Applying an opaque eye mask prevents damage to the newborn’s retinas and corneas from the phototherapy light. 47. A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make? A. “You can bathe and dress your baby if you’d like to.” B. “If you don’t hold the baby, it will make letting go much harder.” C. “You should name the baby so she can have an identity.” D. “I’m sure you will be able to have another baby when you’re ready.” ANS: Offer the parents the choice of holding the infant in their arms. 48. A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make? A. “You will need to stay in a side-lying position for 30 minutes after each dose.” lOMoARcPSD|11700591 B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.” C. “You will receive a magnesium supplement immediately following therapy.” D. “You will need to have a full bladder before the therapy begins.” ANS: Assist the woman to maintain a supine position with a lateral tilt or a side-lying position for 30 to 40 minutes after insertion. Initiate oxytocin for induction of labor no sooner than 4 hours after the last dose of misoprostol was administered, following agency protocol, if ripening has occurred and labor has not begun. 49. A nurse is assessing a newborn who was born post-term. Which of the following findings should the nurse expect? A. Nails extending over tips of fingers B. Large deposits of subcutaneous fat C. Pale, translucent skin D. Thin covering of fine hair on shoulders and back ANS: Overgrown nails, abundant scalp hair, visible creases on palms and soles of feet, minimal fat deposits etc. 50. A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work. Which of the following information should the nurse include in the lOMoARcPSD|11700591 teaching? A. “Thawed (defrosted) breast milk can be refrigerated for up to 72 hours.” B. “Breast milk can be stored in a deep freezer for 12 months.” C. “Breast milk can be stored at room temperature for up to 12 hours.” D. “Thawed breast milk that is unused can be refrozen.” ANS: Freshly expressed or pumped milk can be stored: At room temperature (77°F or colder) for up to 4 hours. In the refrigerator for up to 4 days. In the freezer for about 6 months is best; up to 12 months is acceptable. 51. A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization? A. A Rh-negative mother who has a Rh-positive infant B. A Rh-positive mother who has a Rh-negative infant C. A Rh-positive mother who has a Rh-positive infant D. A Rh-negative mother who has a Rh-negative infant ANS: Rho(D) immune globulin is used to prevent antibodies from forming when a mother has Rh- negative blood and the baby is Rh-positive so that antibodies from the mother that crosses the placenta and attacks fetal blood cells causing hemolysis. lOMoARcPSD|11700591 52. A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Provide a stimulating environment B. Monitor blood glucose level every hr. C. Initiate seizure precautions. D. Place the infants on his back with legs extended. ANS: Initiate seizure precautions since signs of withdrawal in neonates are Irritability • Seizures • Hyperactivity • High-pitched cry • Tremors • Exaggerated Moro reflex • Hypertonicity of muscles. 53. A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching? A. “You should feel a tugging (pulling) sensation when the baby is sucking. B. You should expect your baby to have two to three wet diapers in 24 hours period C. “Your baby’s urine should appear dark and concentrated”. D. “Your breast should stay firm after the baby breastfeeds”. ANS: Firm tugging sensation on nipple as infant sucks but no pain. Has at least three substantive bowel movements and six to eight wet diapers every 24 hours after day 4. 54. A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching? lOMoARcPSD|11700591 A. “This test will confirm fetal lung maturity “. B. “This test will determine adequacy of placental perfusion”. C. “This test will detect fetal infection”. D. “This test will predict maternal readiness for labor”. ANS: The goal of a nonstress test is to provide useful information about your baby's oxygen supply by checking his or her heart rate and how it responds to your baby's movement. The test might indicate the need for further monitoring, testing or delivery. Normally, a baby's heart beats faster when he or she is active later in pregnancy. However, conditions such as fetal hypoxia when the baby doesn't get enough oxygen can disrupt this response. 55. A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol? A. A client who has active genital herpes B. A client who has gestational diabetes mellitus C. A client who has a previous uterine incision D. A client who has placenta previa ANS: Induction of labor with misoprostol contraindicates with prior classic uterine incision, active genital herpes infection, placenta or vasa previa, & transverse fetal lie. And there is no study that shows there a contraindication to a client with gestational diabetes. lOMoARcPSD|11700591 56. A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider? A. Blood pressure 148/94 mmHg B. Respiratory rate 14 breath/min C. Urinary output 20 mL/hr. D. 2+ deep tendon reflexes ANS: The client’s urine output should be at least 25 to 30 mL/hr. to promote adequate excretion of magnesium. The nurse should stop the infusion & notify the provider. 57. A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Instruct the client to use effleurage B. Apply counter pressure to the client sacral. C. Assist the client with patterned-paced breathing. D. Teach the client the technique of biofeedback. ANS: Application of sacral counterpressure helps the woman cope with the sensations of internal lOMoARcPSD|11700591 pressure and pain in the lower back. It is especially helpful when back pain is caused by pressure of the occiput (back of the head) against spinal nerves, therefore counterpressure lifts the occiput off these nerves, thereby providing pain relief. 58. A nurse is caring for newborn immediately following birth and notes a large amount of mucus in the newborn’s mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the steps into the box on the placing them in the selected order of performance. Use all the steps.) A. Compress the bulb syringe B. Place the bulb syringe in the newborn’s mouth C. Use the bulb syringe to suction the newborn’s nose. D. Assess the newborn for reflex bradycardia ANS: , B, C, D Bulb must be compressed before inserting tip into mouth. 59. A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as having the lowest incidence of GDM? A. Asian B. Non-Hispanic White American C. Hispanic D. African American lOMoARcPSD|11700591 ANS: GDM is more likely to occur among Hispanic, Native American, Asian, and African American women than Caucasians and is likely to recur in future pregnancies; the risk for development of overt diabetes in later life is also increased. 60. A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. “It burns when I urinate.” B. “My feet are really swollen today.” C. “I didn’t have lunch today, but I have breakfasted this morning.” D. “I have been seeing spot this morning.” ANS: During pregnancy, you're more susceptible to urinary tract infections. Most commonly, such infections are confined to the bladder, when they are known as cystitis. Symptoms of cystitis include a frequent, urgent need to urinate and a painful burning sensation when passing urine; there may be some blood in your urine. 61. A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? A. “Your stomach will empty rapidly” B. “You should expect your uterus to double in size” C. “You should anticipate nasal stuffiness” D. “Your nipples will become lighter in color” lOMoARcPSD|11700591 ANS: The uterus rises gradually to the level of the umbilicus at 22 to 24 weeks of gestation and nearly reaches the xiphoid process at term. 62. A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? A. “your contraction will become more intense when walking” B. “you will have dilation and effacement of the cervix” C. “you will have bloody show” D. “your contraction will become temporally regular” ANS: During false labor contraction occur irregularly or become regular only temporarily. Often stop with walking or position change. 63. A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication? A. Hypnosis B. Polyuria C. Bilateral crackles D. Hyperglycemia ANS: Since opioids can sometimes cause slow breathing or other breathing problems, bilateral crackles are one of the adverse effects of epidural block with opioid analgesia. lOMoARcPSD|11700591 64. A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plans to conduct? A. Group B strep culture B. 1-hr glucose tolerance test C. Rubella titer D. Blood type and Rh ANS: A glucose challenge test is usually conducted between 24 and 28 weeks of pregnancy. Abnormal glucose levels may indicate gestational diabetes. 65. A nurse is caring for a client who has bacterial vaginosis. Which of the following medication should the nurse expect to administer? A. Metronidazole B. Fluconazole C. Acyclovir ANS: Treatment of bacterial vaginosis with oral metronidazole (Flagyl) is most effective, although vaginal preparations (e.g., metronidazole gel, clindamycin cream) are also used. 66. A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? A. Place a snug dressing on the client’s nipple when not breastfeeding. B. Ensure the newborn’s mouth is wide open before latching to the breast. C. Encourage the client to limit the newborn’s feeding to 10 min on each breast. D. Instruct the client to begin the feeding with the nipple that is most tender. ANS: To decrease nipple discomfort, the mother has to make sure that the baby's mouth is open wide before latching him or her on to the breast. lOMoARcPSD|11700591 67. A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect? A. Minimal arm recoil B. Popliteal angle of less than 90 C. Creases over the entire sole D. Sparse (thin) lanugo ANS: Fine hair (lanugo) covering much of the body is expected with preterm newborn. 68. A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include? A. Focusing on controlling body functions B. “Synchronized breathing will be required during hypnosis” C. “Hypnosis can be beneficial in you practiced it during the prenatal period” D. “Hypnosis does not work for controlling pain associated with labor”. ANS: Hypnosis techniques used for labor and birthplace an emphasis on enhancing relaxation and diminishing fear, anxiety, and perception of pain. Women using this technique report a greater sense of control over painful contractions and a higher level of satisfaction with their childbirth experiences. lOMoARcPSD|11700591 69. A nurse is caring for client who is in active labor. Following epidural placement, the nurse a maternal blood pressure of 98/58 mmHg and minimal FHR variability on the fetal monitor. Which of the following images indicates the action the nurse should take? ANS: turn the client to her side before calling the health care provider (HCP)