Maternal Newborn CMS 2023
A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
Increased urination
A nurse is planning care for a client following chorionic villus sampling. The nurse should recognize that the client is t risk for developing which of the following complications>
Infection
A nurse is admitting a client to the birthing unit who reports her contractions started 1hr ago. The nurse determines the client is 80% effaced and 8cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
Postpartum hemorrhage
A nurse is providing discharge instructions to a client who is 24hr postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching?
"Apply ice to your breasts using a 15 minutes on, 45 minutes off schedule"
A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?
"I should avoid becoming pregnant for at least 1 month following the immunization"
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
"I will drink water before the test until my bladder feels full."
A nurse is providing teaching to the parents of a newborn about Plastibell circumcision?
"Notify the provider if the end of your baby's penis appears dark red."
A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client?
"Notify your baby's pediatrician if he urinates less than six times a day"
A nurse is providing teaching about the expected effect magnesium sulfate to a client who is at 28 weeks of gestation and has preclampsia. Which of the following responses by the nurse is appropriate?
"This medication prevents seizures"
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?
"You can bathe and dress your baby if you'd like to."
A client who is at 16 weeks of gestation asks a nurse how to prepare her toddler to have a younger sibling. Which of the following statements should the nurse make?
"You should give your toddler a gift from the baby when she visits you in the facility"
A nurse is conducting a class for a group of clients about birth control. Which of the following information should the nurse include in the teaching?
"You should have an annual examination to assess your diaphragm"
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
"You should have your provider refit you for a new diaphragm"
A nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
"Your partner will apply steady pressure with a tennis ball to your lower back"
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?
20 mL/hr urine
A nurse is caring for a client who is receiving prenatal care and is at her 24 week appointment. Which of the following laboratory test should the nurse plan to conduct?
1-hr glucose tolerance test
A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain?
-Apply countepressure to the sacral area -Ambulate the client in the hallway
A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?
-Ask the client to lie on her back and her knees flexed -Position one hand around the top of the fundus and on hand just above the client's symphysis pubis -Rotate the upper hand to massage the client's uterus while downward pressure to compress the fundus
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccines?
-Tdap -Inactivated influenza
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?
1 cup cooked broccoli
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as contraindication to the use of suppository?
3rd degree lacerations
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
A client who is at 32 weeks of gestation and reports seeing floating spots
A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
A newborn who is 10hr old and has new onset tachypnea
A nurse is assessing a client who is 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
Absent deep-tendon reflexes
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
Administer broad spectrum antibiotics
A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
Administer ceftriaxone
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
Allow the baby to feed at least every 3hr
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
BP 88/58 mmHg
A nurse is providing dietary teaching to a client who is at 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet?
Baked chicken
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
Bathe the newborn before initiating skin to skin contact
A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor?
Chorioamnionitis
A nurse is caring for a client who is at 6 weeks of gestation and reports nausea and vomiting. Which of the following recommendations should the nurse make?
Consume foods served at cool temperatures
A nurse is caring for a client who is 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following type of isolation precautions should the nurse initiate?
Contact
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?
Cool, clammy skin
A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction?
Cover the newborn's bladder with sterile, non-adherent dressing
A nurse is assessing a client during the first prenatal visit. The client reports March 20 as her last menstrual period. Use Naegele's rule to calculate the estimated date of delivery.
December 27th
A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arm, the mother states, "No, the baby is too tired to be held.". Which of the following actions should the nurse take?
Demonstrate how to hold the newborn and allow the client to practice
A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect?
Dorsiflexion
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
Ensure the newborns eyes are closed beneath the shield
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12 which of the following foods should the nurse recommend?
Fortified Soy milk
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
Hearing loss
A nurse is assessing a newborn who was exposed to cocaine in utero. Which of the following findings should the nurse expect?
High-pitched cry
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for conception. Which of the following statements by the client indicates an understanding of the teaching?
I should increase my calcium intake while on this medication
A nurse is caring for a newborn following delivery. Which of the following actions should the nurse take first?
Identification band on the newborn
A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?
Inability to void
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
Ketones
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
Lentils
A nurse is using Nagele's Rule to calculate the expected delivery date of a client who reports that the first day of her last menstrual cycle was July 28th. Which of the following dates should the nurse document as the client's expected delivery date?
May 5th
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify which of the following factors places the client at risk for an infection?
Midline episiotomy
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?
Muscle weakness
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?
Painless, vaginal bleeding
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Perform a vaginal examination by applying upwards pressure on the presenting part
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
Petechiae
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
Platelet count 60,000/mm3
A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
Platelets 100,000/mm3
A nurse is caring for a newborn who is 6hr old and has a bedside glucometer reading of 65 mg/dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
Recheck prior to next feeding
A nurse is discussing risk factors of postpartum hemorrhage with a newly licensed nurse. Which of the following conditions is a risk factor for postpartum hemorrhage that the nurse should include in the teaching?
Retained placental fragments
A nurse is caring for a client who is in preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?
Serum medication level
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
Single palmar creases
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
Six contractions in 10 min
A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?
The newborn is beginning to cough
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?
The client has a fundal height of 38cm
A nurse in a providers office is caring for a 20 year old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
This procedure determines if your baby has genetic or congenital disorders
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
Transmission can occur via the saliva and urine of the newborn
A nurse is caring for a client who is in labor and just receiving epidural anesthesia. The client's blood pressure is 90/58 mmHg. Which of the following actions should the nurse take?
Turn the client on their side
A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?
Use an automatic puncture device on the heel
A nurse is assessing a client who is 6hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Uterine tenderness
A nurse is assisting the provider to administer dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
Verify that the informed consent is obtained prior to administration
