Maternal newborn practice test B with rationale

A nurse is teaching a client who has pregestational type 1 DM 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 N/V." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

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 taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hours. Which of the following statements should the nurse make?

"Your provider will insert an interuterine pressure cathether to monitor the strength of your contractions." Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.

A nurse on an antepartum unit is caring for 4 pts. Which of the following pts. should the nurse identify as the priority?

A client who is at 34 weeks of gestation and reports epigastric pain. When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

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 newborns eyes while under the therapy light Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

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

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 caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

Have calcium gluconate readily readily available The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.

A nurse is teaching a client who is at 35 weeks gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Massage the clients fundus The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the med?

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.

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 newborns cry sounds clear The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

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 BP every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

The nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring

Oligohydraminos The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "what effects will this procedure have on my sex life?" which of the following responses should the nurse make?

This procedure should have no effect on your sexual performance or adequacy. The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.

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 a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Transition The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.

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

Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.

A nurse is caring for a newborn who has transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. which of the following laboratory results should the nurse report to the provider?

platelets 50,000/mm^3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is teaching a client who is 24 weeks regarding a 1 hour glucose tolerance test. Which of the following statements should the nurse include in the teaching?

"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 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.

A nurse is teaching a client who is in preterm labor about Terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

"I will have blood tests because my potassium might decrease." An AE of Terbutaline is hypokalemia.

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

"I will need this medication if I have an amniocentesis." Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

"Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?

"This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is prenant. Which of the following responses should the nurse make?

"You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?

"You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.

A nurse is preparing to administer azithromycin to a client who is 16 weeks and has a positive chlamydia culture. The prescription states "administer azithromycin 1g orally now." Available is 250mg tablets. How many tablets should you give?

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A nurse is planning discarge for a client who is 3 days postpartum. Which of the following nonpharmalogical interventions should the nurse include in the plan of care for lactation supression?

Apply cabbage leaves to the breasts Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take?

Apply internal upward presence to the presenting part using two gloved fingers Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.

A nurse is caring for a client who is in labor and who's fetus is in the right occiput posterior position. The client is dilated to 8cm and is reporting back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her uterus to the right about the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty her bladder The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

A nurse is reviewing lab results of a newborn who is 4 hours old. Which of the following findings should the nurse report to the provider?

Bilirubin 9mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.

A nurse is caring for a client who is at 41 weeks gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

Biophysical profile The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is reviewing the lab report of a newborn who is 24 hours old. Which of the following results should the nurse report to the provider?

Blood glucose 30mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are greater than 24 hr old should have a blood glucose of 50 to 90 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.

A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain?

Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

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 CI to oral contraceptives?

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives.

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

Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count.

A nurse is planning care for a client who is 2 hours 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 Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Determine respiratory function The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse in the antepartum clinic is assessing a clients adaption to pregnancy. The pt. states that she is, "happy one minute and crying the next." The nurse should interpret the pt's statement as indication of which of the following?

Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

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

Exhibit 1: Diagnostic Results​Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-negative Exhibit 2: Medication Administration Record​Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM onceNalbuphine 10 mg IV every 3 hr PRN pain Exhibit 3: Progress Report1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 - Fetal heart rate 130/min with moderate variabilityUterine contractions q 5 to 8 min lasting 30 to 60 sec durationUterine contractions palpated at 1+ intensityClient reports uterine contraction pain of 2 on a scale of 0 to 10 answer: administer Terbutaline The nurse should administer Terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth.

A nurse is caring for a client who is 22 weeks and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Explain to the client this is an expected occurence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation 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 melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is reviewing the lab results for a client who is 10 weeks. Which of the following lab findings should the nurse report to the provider?

Hemoglobin 10g/dl A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider.

A nurse is caring for a client who is at 35 of gestation and has placenta previa. Which of the following actions should the nurse take?

Initiate continuous external fetal monitoring The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth

A nurse is planning care for a client who is to undergo a NST. Which of the following actions should the nurse include in the plan of care?

Instruct the client to press the button provided each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse in a women's 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 The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones?

Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the clients abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?

LLQ The fetal heart tones of a fetus in the left occipital anterior position are best heard in the LLQ.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

The nurse is providing discharge teaching to the parents of a newborn about carseat safety. Which of the following instructions should the nurse include?

Place the retainer clip at the level of the newborns armpits The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.e the retainer clip at the level of the newborns armpits

A nurse is teaching a client who has a new prescription for combined oral contraceptives about AE of the medication. For which of the following findings should the nurse instruct the client to notify the provider?

SOB The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

A nurse is calculating a client's expected d.o.b using Nagele's rule. The client tells the nurse that her last menstrual cycle started on Nov. 27th. Which of the following dates is the client's expected d.o.b.?

September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is assessing a newborn who is 12 hours old. Which of the following manifestations requires intervention by the nurse?

Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.lling of the face

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

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 assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

The nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

You should leave the diaphragm in place for at least 6 hours after intercourse The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

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

You should take the medication within 72 hours of having unprotected sex Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is teaching a client who is at 35 weeks gestation and has a -description for a nonstress test. Which of the following statements should the nurse include in the teaching?

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