Questions 74

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ATI Nur 232 Maternity Final Exam SP24 Questions

Extract:

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F).


Question 1 of 5

Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer: D

Rationale: Administering acetaminophen orally is appropriate to reduce fever, which may indicate infection, while further evaluation is conducted.

Extract:

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus.


Question 2 of 5

What information should the nurse give to the client?

Correct Answer: A, E

Rationale: A cesarean section prevents neonatal herpes transmission if lesions are present at labor. Valacyclovir suppressive therapy after 36 weeks reduces outbreak risk.

Extract:

A nurse is providing nutritional guidance to a parent of a newborn.


Question 3 of 5

Which statement by the parent indicates an understanding of the teaching?

Correct Answer: C

Rationale: Waiting to give fruit juice until 6 months aligns with recommendations to avoid early introduction of sugary drinks.

Extract:

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F).


Question 4 of 5

Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer: D

Rationale: Administering acetaminophen orally is appropriate to reduce fever, which may indicate infection, while further evaluation is conducted.

Extract:

Vital Signs at 0700 hrs: Temperature: 36.6°C (97.9°F), Pulse: 85/min, Respiratory rate: 20/min, Blood pressure: 180/99 mm Hg. Nurses' Notes at 0700 hrs: Client reports, "I have had a headache for 2 days. Tylenol does not relieve it." Client states, "I have blurred vision and dizziness." Client reports swelling of their feet. 2+ pitting edema of the lower extremities noted bilaterally. Deep tendon reflexes 3+, absent clonus. Fetal heart tones (FH) 150/min. Medical History: Gravida 4 Para 3, 33 weeks of gestation, Allergies: Sulfa, Height: 165 cm (66 in), Weight: 82 kg (180 lb), BMI: 30.6.


Question 5 of 5

Select the 4 assessment findings the nurse should report to the provider.

Correct Answer: A, B, D, G

Rationale: Headache unrelieved by Tylenol, blurred vision and dizziness, 2+ pitting edema, and blood pressure of 180/99 mm Hg are concerning signs of preeclampsia, requiring immediate reporting. Swelling of feet is common and less urgent unless accompanied by other symptoms. Deep tendon reflexes 3+ and fetal heart tones 150/min are normal.

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