Question

A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Answer 1

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

Warm heel: Increases capillary blood flow for easier sampling.

🔷 Cleanse heel: Prevents infection by removing surface contaminants.

🔷 Puncture & collect: Get capillary blood promptly for accurate testing.

🔷 Apply pressure: Stops bleeding and avoids bruising at the site.

🔷 Bandage: Protects the site from infection and friction.

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Answer 2

Correct Answers:

Assist the client to empty her bladder.

Rationale :

🟢 Deviated, elevated fundus after birth often indicates a full bladder displacing the uterus.

🟢 A full bladder prevents effective uterine contraction, increasing risk for hemorrhage.

🟢 Emptying the bladder allows the uterus to contract and return midline.

🟢 Monitoring and medications are supportive, but bladder care is priority.

🟢 Early intervention reduces complications and restores uterine tone.

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Answer 3

Correct Answers:

Hemoglobin 18 g/dL (11 to 16 g/dL)

Rationale :

🔴 Elevated hemoglobin signals hemoconcentration due to severe dehydration.

🔴 Hyperemesis gravidarum causes prolonged vomiting, leading to volume loss.

🔴 This concentration effect increases blood viscosity and risk for clots.

🔴 Other options are within expected ranges or unrelated.

🔴 Prompt correction of dehydration prevents maternal/fetal harm.

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Answer 4

Correct Answers:

A client who received magnesium sulfate during labor

Rationale :

🔵 Magnesium sulfate is given for preeclampsia/eclampsia, with high risk for respiratory depression postpartum.

🔵 Monitoring reflexes, respiration, and urine output is essential for toxicity detection.

🔵 Other clients have less acute needs; safety is the top priority.

🔵 Delayed assessment may miss life-threatening complications.

🔵 Rapid evaluation allows for early intervention if toxicity is found.

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Answer 5

Correct Answers:

Recurrent urinary tract infections

Rationale :

🟣 Diaphragm use is linked to increased risk of UTIs due to pressure on urethra and altered vaginal flora.

🟣 Those with recurrent UTIs should use alternative contraception to avoid further infections.

🟣 Other options (tobacco use, history of GBS, DVT) do not directly contraindicate diaphragm use.

🟣 Proper screening prevents complications and discomfort.

🟣 Nurse teaching helps patients choose safest, most effective method.

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Answer 6

Correct Answers:

Move the seat as far away as possible from the steering wheel.

Rationale :

🟡 Distance between abdomen and steering wheel reduces injury risk in crashes. 🟡 Lap belt should be below uterus, not high on abdomen. 🟡 Shoulder harness never across gravid uterus. 🟡 Airbags should not be disabled—added protection in crashes. 🟡 Proper seat placement and restraints protect mother and fetus.

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Answer 7

Correct Answers:

Insert the suppository along the posterior vaginal wall.

Rationale :

🔴 Posterior wall insertion allows optimal medication absorption and effectiveness. 🔴 Ensures correct placement with gravity and anatomy. 🔴 Petroleum jelly impairs absorption; prone position unnecessary. 🔴 Insert to depth of 5 cm, direction is most important. 🔴 Technique affects cure rates for vaginal candidiasis.

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Answer 8

Correct Answers:

A single crease in the palm

Rationale :

🟢 Simian crease (single transverse palmar crease) is characteristic of Down syndrome.

🟢 It reflects altered fetal development and occurs in many infants with trisomy 21.

🟢 Other findings (lip notch, extra digits, foot inversion) are not typical for Down syndrome.

🟢 Recognizing key features supports early diagnosis and family counseling.

🟢 Early interventions improve outcomes for these newborns.

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Answer 9

Correct Answers:

"I will need to attend a support group when I get home."

Rationale :

🟣 Molar pregnancy can cause grief, anxiety, and fear about future fertility. 🟣 Emotional support is vital during physical and psychological recovery. 🟣 Support groups help women share experiences and find resources. 🟣 Chemotherapy, palliative care, and amniocentesis are not routine post-molar pregnancy. 🟣 Psychosocial care aids full recovery.

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Answer 10

Correct Answers:

The newborn's fingers curl around the nurse's finger when placed in the newborn's palm.

Rationale :

🔵 Palmar grasp reflex is normal and expected in term newborns.

🔵 It demonstrates intact neurologic function at birth.

🔵 Absence may indicate neuro or muscular disorders.

🔵 Other reflexes described (rooting, Babinski, eye closure) are separate primitive reflexes.

🔵 Reflex assessment guides newborn neurologic evaluation.

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ATI PN Maternal Newborn-2023B

No.

1 :
A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

2 :
A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

3 :
A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following manifestations should the nurse expect?

4 :
A nurse has just received change-of-shift report about four clients who are postpartum. Which of the following clients should the nurse plan to see first?

5 :
A nurse in a provider's office is reviewing the medical record of a client who is requesting a diaphragm. Which of the following findings in the client's history should the nurse identify as a contraindication for this type of contraception?

6 :
A nurse is reinforcing teaching about safety precautions to take when driving a car with a client who is in the first trimester of pregnancy. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is administering a miconazole vaginal suppository to a client who has vaginal candidiasis. Which of the following actions should the nurse take?

8 :
A nurse in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?

9 :
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

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ATI PN Maternal Newborn-2023B

No.

1 : A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

2 : A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

3 : A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following manifestations should the nurse expect?

4 : A nurse has just received change-of-shift report about four clients who are postpartum. Which of the following clients should the nurse plan to see first?

5 : A nurse in a provider's office is reviewing the medical record of a client who is requesting a diaphragm. Which of the following findings in the client's history should the nurse identify as a contraindication for this type of contraception?

6 : A nurse is reinforcing teaching about safety precautions to take when driving a car with a client who is in the first trimester of pregnancy. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is administering a miconazole vaginal suppository to a client who has vaginal candidiasis. Which of the following actions should the nurse take?

8 : A nurse in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?

9 : A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

10 : A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

1 :
A nurse is obtaining a capillary blood sample from a newborn for phenylketonuria testing. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

2 :
A nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

3 :
A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following manifestations should the nurse expect?

4 :
A nurse has just received change-of-shift report about four clients who are postpartum. Which of the following clients should the nurse plan to see first?

5 :
A nurse in a provider's office is reviewing the medical record of a client who is requesting a diaphragm. Which of the following findings in the client's history should the nurse identify as a contraindication for this type of contraception?

6 :
A nurse is reinforcing teaching about safety precautions to take when driving a car with a client who is in the first trimester of pregnancy. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is administering a miconazole vaginal suppository to a client who has vaginal candidiasis. Which of the following actions should the nurse take?

8 :
A nurse in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?

9 :
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?