Maternity/Pediatric Nursing Quiz 1

A nurse is reinforcing education about the prevention of newborn abduction with a client who recently gave birth. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"An alarm will sound if someone removes my baby's safety device." (or if someone takes baby outside the facility parameter)

A nurse is reinforcing teaching with a client who has asked about continuing routine exercise during pregnancy. Which of the following responses should the nurse make?

"Drink plenty of water after exercising."

A nurse is reinforcing discharge teaching about home care with the parent of a newborn. Which of the following instructions should the nurse include?

"Ensure the water temperature during your newborn's bath is maintained at 100 degrees Fahrenheit." (Avoid cold stress and risk of burn injuries)

A nurse is reinforcing teaching with a client who has a new prescription for medroxyprogesterone acetate injection for contraception. Which of the following statements by the client indicates understanding of the teaching?

"I am likely to gain weight while taking this medication." (Common side effect)

A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching?

"I can use water-soluble lubricant when my partner wears a latex condom." (Any other lubricant can compromise the integrity of the condom)

A nurse is reinforcing teaching with a client who is at 8 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching?

"I should expect to have white vaginal discharge during pregnancy." (Leukorrhea, happens when increased estrogen and progesterone occurs)

A nurse is reinforcing home care safety with the guardian of a newborn prior to discharge. Which of the following statements by the guardian indicates understanding of the teaching?

"I should place my baby's crib away from the windows." (Prevent drafts or blind or drapery danger)

A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I should wake up my baby to feed during the night." (Every 3 hr schedule, first 48 hr)

A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will apply cold cabbage leaves to my breasts throughout the day." (Prevent engorgement, can also use ice)

A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching?

"I will ask the nurse to take my baby to the nursery if I need to leave my room." (Never leave the newborn unattended)

A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension with a client who is at 16 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching?

"I will lie on my left side with my head elevated on a pillow." (Prevents compression of the vena cava and subsequent hypotension)

A nurse is reinforcing teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will position the retainer clip at the level of the baby's armpits." (Not over the neck or abdomen)

A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will report any drainage from my baby's umbilical cord." (Manifestations of an infection)

A nurse is reinforcing teaching about car seat safety with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching?

"If my baby rides in a car with no back seat, the passenger air bag must be turned off." (Prevent injuries caused by air bag)

A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughter's room. Which of the following responses should the nurse make?

"Let me wash my hands and then I'll take the baby to his mother." (Only facility personnel are allowed to transport the newborns)

A nurse is reinforcing teaching with a client about combined oral contraceptives. Which of the following statements should the nurse make?

"Oral contraceptives can offer protection against ovarian cancer." (and endometrial and colon cancers)

A nurse is reinforcing teaching with the guardian of a newborn who is receiving phototherapy for hyperbilirubinemia. Which of the following statements should the nurse make?

"Remove your baby's eye mask during feedings." (To allow for visual contact and bonding)

A nurse is reinforcing teaching with a client who is experiencing preterm labor and has a new prescription for nifedipine. Which of the following statements should the nurse include?

"This medication might cause your face to be flushed." (Common adverse effect)

A nurse in a provider's office is reinforcing teaching with a client. Which of the following statements should the nurse include?

"You might experience a metallic taste in your mouth while taking your medication." (Common side effect)

A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include?

"You must be at least 37 weeks of gestations before you can use hydrotherapy." (Contraindicated for clients less than 37 weeks for risk of preterm labor)

A nurse is reinforcing teaching about preventing urinary tract infections with a client who is at 25 weeks of gestation. Which of the following instructions should the nurse include?

"You should empty your bladder before you go to bed at night" (Prevent stasis of urine, full bladder provides bacterial growth)

A nurses reinforcing teaching about the newborn home safety precautions with a group of guardians. Which of the following instructions should the nurse include?

"You should ensure that crib slats are no more than 2.25 inches apart." (Prevent entrapment, fractures and suffocation)

A nurse is reinforcing teaching about a nonstress test with a client who is at 33 weeks of gestation. Which of the following statements should the nurse include?

"You will press a button when you feel the baby move." (Monitors for accelerations in the FHR)

A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching?

"Your fluid intake will be limited to no more than 125 milliliters per hour." (To prevent fluid overload)

A nurse is contributing to the plan of care for a newborn following information should the nurse include when helping to develop the newborn's plan of care? (SATA)

-Maternal group B strep (GBD) status -APGAR score -Type of birth

A nurse is caring for a client who is 48 hr postpartum following a vaginal birth. Which of the following findings should the nurse report to the provider? (SATA)

-Warm, tender area on the calf -Dysuria -Cracked nipples

A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider?

2+ urinary protein (Manifestation of preeclampsia)

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?

A client who is at 37 weeks of gestation and reports a persistent headache. (Manifestation of preeclampsia)

A nurse is collecting data from a client who is at 33 weeks of gestation and has received terbutaline. The nurse should recognize that which of the following findings indicates that the medication has had a therapeutic effect?

A decrease in uterine contractions (Tocolytic medication, relaxes the smooth muscle of the uterus)

A nurse is collecting data from a client who is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider?

Absent deep-tendon reflexes (Indication of toxicity, can lead to cardiac arrest)

A nurse is contributing to the plan of care for a client who has eclampsia. Which of the following interventions should the nurse plan to include as the priority immediately following a seizure?

Administer oxygen via facemask at 10 L/min. (ABC approach, increase oxygen)

A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider?

Apical heart rate of 90/min while crying

A nurse is reinforcing teaching with a client who is pregnant and will undergo a 1-hr glucose tolerance test. Which of the following instructions should the nurse include?

Avoid caffeine in the morning of the test. (It can increase glucose levels)

A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

Blood glucose 28 mg/dL (Below expected range of 40)

A nurse is collecting data from a client who is at 36 weeks gestation during a prenatal examination. Which of the following findings should the nurse report to the provider?

Blurred vision (Indication of preeclampsia)

A nurse is collecting data from a client who is at 37 weeks of gestation. Which of the following findings should the nurse report to the provider?

Blurred vision (Manifestation of gestational HTN or preeclampsia)

A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication?

Cessation of uterine contractions (Used to decrease uterine contractions)

A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first?

Check the newborn's blood glucose level (Use nursing process)

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and reports having constipation. Which of the following information should the nurse include?

Consume 28 g of fiber per day (Help relieve constipation)

A nurse is reinforcing teaching with a client who is at 20 weeks of gestational diabetes mellitus. Which of the following should the nurse include in the teaching?

Consume at least 2,000 cal/day (Ensure adequate glucose intake and prevent hypoglycemia)

A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include?

Consume small meals frequently each day (Avoid an empty stomach, to decrease nausea)

A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity? (SATA)

Decreased respiratory rate, Decreased level of consciousness, Double vision.

A nurse is collecting data from the parent of a newborn immediately following birth. The parent states, "She is so tiny. We don't know how to pick her up without hurting her." Which of the following actions should the nurse take first to promote parent-newborn attachment?

Demonstrate to the parents how to hold the newborn. (Encourage contact with newborn, and ensure safety of the newborn)

A nurse is collecting data from a client who is a primigravida and has hyperthyroidism. Which of the following findings should the nurse expect?

Diaphoresis (Expected findings)

A nurse is assisting with the care of a client who received carboprost tromethamine 2 hr ago for a postpartum hemorrhage. The nurse should identify which of the following findings indicates an adverse effect of the medication?

Diarrhea (As well as: fever, headache, nausea, vomiting and chills)

A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 hr following birth? (SATA)

Diuresis, Discharge of clear yellow fluid from the breasts, Lower abdominal cramping

A nurse is contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend in the plan?

Drink 2 L of water per day. (Decrease reabsorption of fluid and prevent drying of stool)

A nurse is collecting data from a client who is at 32 weeks gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

Epigastric pain (Indicate decreased liver perfusion, lead to hemorrhage)

A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy?

Epigastric pain (Potential complication of pregnancy, manifestation of preeclampsia)

A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take?

Explain to the client that they will receive the hepatitis B immune globulin immediately. (Decrease the risk of transmission to the fetus)

A nurse is assisting with monitoring a client after an amniocentesis. Which of the following findings should the nurse expect?

FHR 120/min (Expected VS should be inspected before and after the procedure)

A nurse is collecting data from a 28-year-old client who is requesting a prescription for an oral contraceptive. Which of the following information in the client's history should the nurse identify as a contraindication for the use of oral contraceptives?

Frequent headaches with visual changes (Indicate cardiovascular condition, HTN.)

A nurse is collecting data who is in the second trimester of pregnancy. Which of the following findings should the nurse report to the provider?

Frequent uterine contractions (Can cause cervix to open and cause preterm labor)

A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine prenatal visit. Which of the following findings in the data from the client's medical record should the nurse report to the provider?

Fundal height (The fundus height should be approx the same number as gestation plus/minus 2 cm)

A nurse is collecting data from a client who gave birth 18 hr ago. Which of the following findings should the nurse identify as an indication of a postpartum complication?

Fundus is palpable at 2 cm above umbilicus. (Should be located at the umbilicus and decrease each day, any higher can lead to uterine atony, hemorrhage)

A nurse is contributing to the plan of care for a client who is at 18 weeks gestation and has just learned that the fetus has trisomy 21. Which of the following resources should the nurse recommend for the client?

Genetic counseling (To provide education about down syndrome; treatment, support and guidance)

A nurse is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?

Glycosuria (Gestational DM complication)

A nurse is assisting with the care of a client who is in the active phase of the first stage of labor. Which of the following findings should the nurse report to the charge nurse?

Green fluid from vagina (Indicates fetus has passed stool and at risk for meconium aspiration syndrome)

A nurse is caring for a client following a cesarean birth. Which of the following actions should the nurse take to decrease the clients risk of developing thrombophlebitis?

Have the client ambulate several times each day. (Increase circulation and prevent thrombophlebitis)

A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort?

Have the client perform relaxing breathing techniques. (Promoting comfort during labor)

A nurse in a postpartum unit is caring for a client who has endometritis and is 48 hr postpartum following a cesarean birth. Which of the following findings should the nurse anticipate?

Heart rate 110/min (Elevated HR is expected finding for endometritis)

A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale of 1 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority?

Help the client ambulate to the toilet (Greatest risk is postpartum hemorrhage from uterine atony)

A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?

Hematocrit 30% (Below the expected range of 33% indicating risk for anemia)

A nurse in an antepartum clinic is reviewing laboratory test results for a group of clients. The nurse should notify the provider of which of the following results?

Hematocrit 31% (Below the expected range for client who is pregnant)

A nurse is assisting in the care of a client who is 24 hr postpartum. Which of the following findings should the nurse report to the provider?

Hgb 7 g/dL (Below expected range, indicating blood loss)

A nurse is caring for a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication?

Hypertension (Can cause both hypertension and hypotension)

A nurse is caring for a client who is in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take?

Inject the medication into the client's vastus lateralis muscle. (Second dose 24 hr later)

A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take?

Insert an indwelling urinary catheter (Decrease kidney perfusion caused by shock can lead to oliguria)

A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include?

Instruct the client to apply warm compress to the affected breast. (Will decrease the inflammation and edema)

A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes?

Intramuscular (Prevent hemorrhage, until vitamin K is produced)

A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse identify as an indication that the client has hyperemesis gravidarum?

Ketonuria (Indication of hyperemesis gravidarum)

When caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse expect the provider to prescribe?

Methylergonovine (Treats postpartum hemorrhage)

A nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend?

Monitor intake and output. (Evaluate the client's hydration status)

A nurse is assisting in the care of a newborn who has sepsis. Which of the following manifestations should the nurse expect?

Nasal flaring (Resp distress, bradypnea, tachypnea or apnea)

A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete?

Neonatal abstinence scoring system (Signs of opioid withdrawal)

A nurse is reinforcing teaching about formula preparation with the parent of a newborn. Which of the following information should the nurse include?

Overdiluted formula can result in inadequate growth. (Concentrated formula can stress the newborn renal system)

A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions should the nurse take?

Place an opaque mask over the newborn's eyes. (Prevent damage to the retina)

A nurse is reviewing the laboratory results of a 4-hr-old newborn. Which of the following findings should the nurse report to the provider?

Platelet count 120,000/mm3 (Below expected range of 150-300,000)

A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include?

Position the bottle at a 45 degree angle during feedings (Allow the newborn to have more control during feedings)

A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in newborns with a group of clients who are pregnant. Which of the following risk factors should the nurse include?

Prematurity (Inadequate surfactant production can lead to RDS)

A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of folic acid supplements is to do which of the following?

Prevent certain kinds of birth defects (Necessary to help prevent neural tube defects)

A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse?

Prolonged deceleration of FHR (Manifestation of an emergent condition; uterine rupture or umbilical cord prolapse)

A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first?

Provide fundal massage for the client

A nurse is planning to reinforce discharge teaching about formula feeding with the guardian of a newborn. Which of the following instructions should the nurse plan to include?

Provide the newborn with 6 to 8 feedings during a 24-hr period. (Schedule newborn feedings every 3 to 4 hr)

A nurse is reinforcing discharge teaching with a client who has mastitis of the left breast. Which of the following instructions should the nurse include?

Pump the affected breast frequently. (Keeping the breast empty while breastfeeding will prevent growth of bacteria and increase comfort)

A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome?

Reactive nonstress test (Indicates fetal well-being and is a desirable outcome)

A nurse is collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider?

Respiratory rate 10/min (Indication of magnesium toxicity)

A nurse is caring for a 12-hr-old male newborn who was delivered from a breech position. Which of the following findings should the nurse report to the charge nurse?

Skin appears jaundiced. (Within the 24 hr, can lead to neuro disorders)

A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use?

Subcutaneous (It relaxes the muscles, should be admin every 4 hr)

A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider? (SATA)

Tachypnea, Nasal flaring, Retactions, Expiratory grunting

A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe the newborn?

The client washes the newborn's hair before unwrapping them. (Helps prevents heat loss)

A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy. Which of the following laboratory values should the nurse recognize as an indication that the therapy has been effective?

Total bilirubin 5 mg/dL (Within the expected range of 1 to 12 mg/dL)

A nurse is assisting with the care of a client who is pregnant and receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider?

Urine output 22 mL/hr (Below expected range of 30mL/hr)

A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect?

Urine output of 3,000 mL in 24 hr

A nurse on a postpartum unit is contributing to the discharge teaching plan for a client. Which of the following instructions should the nurse suggest for the plan?

Use a firm mattress in the newborn's crib (Decrease the risk of sudden infant death syndrome-SIDS)

A nurse in a clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Use an ultrasound stethoscope to listen to fetal heart tones. (Should be heard at the end of 1st trimester)

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings should the nurse identify as an indication of infection?

WBC 35,000/mm3 (Greater than 30,000 could indicate infection)

A nurse is planning to perform a blood collection via heel stick on a newborn. After performing hand hygiene and donning gloves, which of the following actions should the nurse plan to take next?

Wrap the newborn's heel with a cloth moistened with warm water. (Allow dilation of the vessels in the area in order to obtain a sample)

A client requests information about the use of a diaphragm for birth control. Which of the following statements should the nurse make?

You will need to replace the diaphragm every 2 years.

A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate?

½ cup dried peas (Pregnant women should consume 400 mcg of folate per day)