Maternal Newborn

A nurse is developing an educational program for adolescents about nutrition during the third trimester of preg. Which of the following statements should the nurse include in the program?

"Consume three to four servings of dairy each day"

A nurse is reviewing the medical record at 1800 for a client who is at 34wks gestation. Based in the chart findings and documentation the nursing plan of care should include which of the following actions?

Administer terbutaline R: administer terbutaline to stop contractions because the lab results indicate that the fetus's lungs are not mature enough for delivery

A nurse is providing discharge teaching to a parent whose newborn has just had a circumcision. Which of the following instructions should the nurse include?

Apply slight pressure with a sterile gauze pad for mild bleeding

A nurse is caring for a client who is at 40 wks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?

Attention-focusing R: Attention-focusing and distraction techniques are types of non-pharmacological care that are effective in receiving labor pain

A nurse is admitting a client to the labor and delivery unit when the client states. my water just broke. Which of the following interventions is the nurse's priority?

Begin FHR monitoring R: The greatest risk to the client to the client and her fetus following a rupture of membranes is umbilical cord prolapse, The nurse should monitor the fetus closely to to ensure well-being. Therefore. this is the priority action the nurse should take.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)

Cholecystitis Hypertension Migraine Headaches

A nurse is assessing a client who is in active labor and notes early deceleration in the FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the the following actions should the nurse take?

Continue monitoring the client

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Cover the newborn's eyes while under the phototherapy light

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect?

Creases over two-thirds of the soles of the feet Molding of the head Lanugo of the shoulders

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purport (ITP). Which of the following findings should the nurse expect?

Decreased platelet count

A nurse us assessing a client who is at 26 wks gestation. Which of the following clinical manifestations should the nurse report to the provider?

Decreased urine output R: increased B/P, proteinuria and decreased fetal activity can be indication of preeclampsia and should be notified to the provider

A nurse in a woman's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?

Iron

A nurse is assessing FHR for a client who is preg. The nurse has determined as left occipital anterior (LOA). To which of the following areas of the clients abdomen should the nurse apply the ultrasound transducer in order to assess the PMI of the fetal heart?

Left lower quadrant R: The fetal heart tones of a fetus in the occipital anterior position are best heard in the left lower quadrant.

A nurse is caring for a pt. who is at 15 wks gestation, is rh-negative, and just had an Amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Monitor the FHR

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Monitor the FHR continuously

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution

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 to a newborn?

Place the newborn skin to skin on the mother's chest

A nurse is providing d/c teaching to the parents of a newborn about using a car seat properly. Which of the following instructions should the nurse include?

Position the car seat rear-facing in the back seat of the vehicle R: The nurse should instruct the parents to position the car seat rear-facing in the back seat of the vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head and weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rear-facing in the backseat until they are 2 years old or reach the height and weight requirements of the car seat manufacturer.

A nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?

Pregestational diabetes mellitus

A nurse is providing prenatal teaching to a client who is at 26 wks. Which of the following positions should the nurse recommend for the client to increase circulation to the placenta?

Side-lying R: avoids compression of the vena cava, decreased circulation in the uterus can lead to having a child who is small for gestational age.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?

Stop suctioning when the newborn's cry sounds clear.

A nurse is assessing a newborn who is 12hr old. Which of the following clinical s/s requires intervention by the nurse?

Substernal chest retractions while sleeping R: can indicate rest distress syndrome in the newborn

A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing o administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary id to identify the client?

The client's room number R: is not acceptable identifier and places the client at risk for a med error

a nurse is performing a newborn assessment. which of the following images should the nurse identify as an indication of spina bifida occulta?

The first picture - looks like a bruise and small opening maybe at top of buttock. The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following s/s should the nurse expect?

Vaginal pressure R: the nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that lead into the tissues

A nurse is providing d/c teaching to a client who had a C-section birth 3 days ago. Which of the following instructions should the nurse include?

You can still become preg if you are breastfeeding R: breastfeeding does not prevent ovulation, nurse should discuss contraception that is safe to use while breastfeeding.

a nurse is assessing a client who is postpartum. The client's fundus is two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of following actions should the nurse take?

assist the client to the bathroom to void

A nurse is speaking with a client who is trying to make a decision about uterine tube occlusion. The client asks what effects will this procedure have on my sec life? Which of the following responses should the nurse make?

v

Math A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available ts 20g magnesium sulfate in 500 ml of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many ml/hr? (round to whole number)

50 ml/hr

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will continue taking my insulin if I experience nausea and vomiting."

A nurse is teaching a group of parents about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?

"I will dress my baby in flame-retardant clothing."

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat foods that appeal to my taste instead of trying to balance my meals"R: Clients who have hyperemeis gravidrum should eat to taste to avoid nausea

A nurse is providing teaching to a client about the physiological changes that occur during preg. The client is at 10 wks of gestation and has a BMI w/in the expected reference range. Which of the following client statements indicate an understanding of the teaching?

"I will likely need to use alternative positions for sexual intercourse"R: The weight of the preg will change positions of sexual intercourse therefore understanding physiological changes during preg

A nurse is caring for a client who has recently experienced a perinatal death. Which of the following statements should the nurse make to the client?

"I'm sad for you"R: the nurse is offering empathy to the client to facilitate further communication about the perinatal death

A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which of the following information should the nurse include?

"Your newborn should appear content after each feeding"

A nurse is teaching a client who is at 24 wks regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in her teaching?

A blood glucose of 130-140 is considered a positive screening result R: The nurse should teach the client that a blood glucose level of 130 to 149 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus (DM)

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider.

An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.

A nurse is assessing a client who is 12 hr postpartum. The client's funds is two finger breadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

Assist the client to the bathroom to void

A nurse is performing vaginal exam for a client who is in active labor and reports back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that the fetus is in the occiput posterior position. Which of the following actions should the nurse take?

Assist the client to the hands and knees position R: The nurse should assist the client into the hands and knees position during contractions. This position can help relieve her back pain and it will enable the rotation of the fetus from the posterior to an anterior occiput position

A nurse is providing teaching about non-pharm pain management to a client who is breast-feeding and has engorgement. The nurse should recommend the application of which of the following items?

Cold cabbage leaves R: The application of fresh, raw cabbage leaves that have been chilled is an effective non pharmacological method to relieve the pain associated with engorgement.

A nurse is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the nurse include when discussing true labor?

Contractions become stronger with walking.

A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best non pharmacological intervention to perform to relieve the client's discomfort?

Counter pressure

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

Demonstrate to the client how to perform a newborn bath.

A nurse is caring for a client who is at 22 wks gestation and reports concern about the blotchy hyper pigmentation of her forehead. Which of the following actions should the nurse take?

Explain to the client this is an expected occurrence R: Melasma, also referred to as the mask of pregnancy, is a blotchy, brown hyper pigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melantonin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70 % of women. Nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?

Hypertension

A nurse is caring for a client who is to receive oxytocin to augment her labor. which of the following findings contraindicates the initiation of the oxytocin infusion and requires notification of the provider

Late decelerations

A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?

Massage the client's fundus

A nurse is teaching clients in a prenatal class about the importance of taking folic acid during preg. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to percent which of the following fetal abnormalities

Neural tube defect R: folic acid sources include fortified cereals, grain products, oranges, artichokes, liver, broccoli and asparagus

A nurse is providing education about the family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family 7-yr old in accepting the new family member?

Obtain a gift from the newborn to present to the sibling

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect?

Petechiae over the head R: Nuchal cord or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head and neck

a nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. which of the following findings should the nurse identify as a risk factor for the development of preeclampsia

Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

A nurse is planing care for a client who is at 24 wks of gestation and reports daily mild headaches. Which of the following instructions should the nurse include in the plan of care?

Recommend that the client perform conscious relaxation techniques daily R: The nurse should include conscious relaxation techniques in the plan of care as a way to relieve tension and reduce stress, which can help decrease and eliminate headaches

A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

Respiratory distress

A nurse is assessing a full-term newborn 15 min after birth. Which of the following findings requires intervention by the nurse?

Respiratory rate of 18/min R: first 30 min's of a newborns life the rest rate can range from 20-100/min. A resp. rate this low at the time requires further evaluation and intervention by the nurse

a Nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?

The person who come sin to take my baby's pictures will be wearing a photo ID badge R: All personnel working on the unit should be wearing a photo identification badge. The nurse should teach the mother to never allow anyone who is not wearing an identification badge to come in contact with her newborn.

A nurse is providing d/c teaching to a client who is postpartum. For which of the following clinical manifestations should the nurse instruct the client to monitor and report to the provider?

Unilateral breast pain R: can indicate mastitis an infection of the breast tissue s/s are chills, fever, malaise and unilateral breast pain

a nurse is caring for a client who is in labor and reports increasing rectal pressure. she is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds. and vaginal examinations reveals that cervix is dilated to 9 cm, the nurse identifies she is in which phase of labor ?

Transition

A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first?

Verify the newborn's identification

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?

Weight gain of 2.2 kg

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

You should take the medication w/in 72 hrs following unprotected sexual intercourse R: considered the emergency contraceptive which inhibits ovulation to prevent conception

A nurse is teaching a client who is at 36 wks of gestation and has a rx for NST. Which of the following statements should the nurse include in the teaching?

You will be offered OJ to drink during the test R: a nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain results.