Questions 88

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ATI NUR223 Absection 4 Maternity Final Exam Questions

Extract:

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling.


Question 1 of 5

Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Lightheadedness and tingling indicate hyperventilation; breathing into a paper bag restores CO2 levels, correcting respiratory alkalosis.

Extract:


Question 2 of 5

What is the most likely cause of early decelerations in the fetal heart rate (FHR) pattern?

Correct Answer: B

Rationale: Early decelerations are caused by fetal head compression during contractions, a benign response.

Extract:

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment.


Question 3 of 5

Which of the following findings should the nurse expect during this phase?

Correct Answer: C

Rationale: In the dependent, taking-in phase, mothers express excitement and focus on their own needs, relying on others for support.

Extract:

A nurse is caring for a client who is pregnant. Vital Signs: 1100: Temperature: 37.2°C (98.9°F), Pulse rate: 80/min, Respiratory rate: 16/min, Blood Pressure: 136/79 mm Hg; 1200: Pulse rate: 90/min, Respiratory rate: 20/min, Blood Pressure: 134/82 mm Hg. Medical History: Gravida 4 Para 3, 32 weeks of gestation, BMI: 32, History of two newborns weighing over 4.5 kg (10 lb), Family history of type one diabetes mellitus (maternal), Fetal heart tones: 140/min via Doppler. Diagnostic Results: 1115: Fasting blood glucose: 138 mg/dL (60 to 105 mg/dL); 1200: Fasting blood glucose: 142 mg/dL (60 to 105 mg/dL), HbA1c: 12% (less than 6.5%); 1220: Urinalysis: Appearance: clear, Color: amber yellow.


Question 4 of 5

Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.

Correct Answer: A,C,D

Rationale: A: Limits glucose spikes. C: Metformin manages gestational diabetes. D: Monitors fetal well-being.

Extract:

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.


Question 5 of 5

The nurse should document what Apgar score for this infant?

Correct Answer: 9

Rationale: Apgar score: Color (1), Heart rate (2), Respiratory effort (1), Muscle tone (1), Reflex irritability (2) = 9.

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