Maternal Newborn Practice 2019 A***
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 (4.8 lb).A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.
A nurse is providing teaching for a client who have 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 comes to take my baby's pictures will be wearing a photo identification badge
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?
Reports of decreased fetal movement
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. MY ANSWER The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse priority?
Massage the client's fundus
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old in accepting the new family memeber?
Obtain an gift from the newborn to present to the sibling
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?
Premature rupture of membranes
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
A newborn who is 18 hr old and has an axillary temperature of 99.9° F. 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 caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider?
Late decelerations MY ANSWER Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe?
Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan?
Remove all clothing form the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?
Respiratory rate 10/min. The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Common SE include: nausea, oliguria, flushed and feeling hot
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?
Lays the newborn across her lap and gently sways
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
A client who is at 11 weeks of gestation and reports abdominal cramping
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g 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?
50 ml/hr
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn. Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure?
Administer oxygen via a nonrebreather mask
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?
Abruptio placenta MY ANSWER Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
BUN 25 mg/dL
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 The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test?
Biophysicial profile
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?
Blurred Vision
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity?
Calcium Gluconate
A nurse is providing teaching about nonpharmological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?
Cold cabbage leaves
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
Depression MY ANSWER The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Substernal Retractions
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
To locate a pocket of fluid MY ANSWER An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?
Vaginal pressure MY ANSWER The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.. A client who has a vaginal hematoma will report persistent vaginal or rectal pain
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?
Verify that the parent's identification band matches the newborn's identification band
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen"
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I should take 600 micrograms of folic acid each day." MY ANSWER A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
FHR 152/min. The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider?
Fundal Height Measurement
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?
Have the client change positions
A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider
Hemoglobin 10 g/dL MY ANSWER A hemoglobin 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 finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
Jaundice MY ANSWER Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Maintain the client of bed rest
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil
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 continously
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?
Petechiae over the head MY ANSWER 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 is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
Report of visual disturbances
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a C-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should be administered?
Naloxone
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Report the client's condition to the local health department
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
Reports increased urinary output. Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
"I can administer oxytocin 4 hours after the insertion of the medication" The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.
A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?
"I will likely need to use alternative positions for sexual intercourse".
A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?
"You can still become pregnant if you are breastfeeding" The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include?
"You should press the handheld button when you feel your baby move."
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible
Acrocyanosis Positive Babinski reflex Two umbilical arteries visible MY ANSWER Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet.Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel.Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age.Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.
A nurse is caring for a client who is pregnant Medical History Gravida 1, Para 041 weeks of gestationInduction of labor due to postdates. Nurses' Notes 1400: Client received epidural anesthesia for reports of a pain level of 7 on a scale of 0 to 10 from uterine contractions.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate.FHR: Baseline 135/min, average variability, accelerations present, no decelerations noted.Oxytocin infusing at 8 milliunit/min. Rate last increased by 2 milliunits/min at 1330. 1415: Client reports feeling light-headed.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderateFHR: Prolonged deceleration of fetal heart rate to 90/min, minimal variability. Vital Signs 1400: Temperature 37.1° C (98.8° F) Heart rate 72/min Respirations16/min Blood pressure 128/76 mm Hg Oxygen saturation 96% 1415: Heart rate 90/min Respiratory rate 20/min Blood pressure 92/50 mm Hg Oxygen saturation 96% Which of the following actions are the nurse's priorities?
Administer a bolus of IV fluids is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. The nurse should plan to administer a bolus of IV fluids to increase the client's blood volume and improve uterine and intervillous space blood flow. Reposition the client to their side is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to turn the client to their side to increase cardiac output and improve uterine and intervillous space blood flow. Apply oxygen at 10 to 12 L/min by nonrebreather mask is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to administer oxygen via nonrebreather mask to increase maternal circulating oxygen levels and improve oxygen transfer through the intervillous spaces to the fetus. Elevate the client's legs is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. Elevating the client's legs will promote blood return to the heart and increase cardiac output. This action will improve uterine and intervillous space blood flow.
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding the newborn should the nurse anticipate? Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation.Birth weight 7 lb 12 oz (3,515 g)Apgar scores 8 at 1 min and 9 at 5 minMaternal history of methadone use during pregnancy. Vital Signs 0700:Heart rate 156/min Respiratory rate 68/min Temperature 37.7° C (99.9° F) Oxygen saturation 97% on room air 1100:Heart rate 174/min Respiratory rate 84/min Temperature 38.2° C (100.8° F) Oxygen saturation 98% on room air Physical Examination 1100: Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Mottled skin noted on extremities. Frequent sneezing. Several loose stools today.
Administer scheduled doses of oral morphine is correct. The nurse should administer scheduled doses of oral morphine to the newborn to decrease manifestations of withdrawal. The dosage of the medication is adjusted based on the NAS score of the newborn. Maintain a low-stimulus environment is correct. Supportive care for a newborn who has NAS includes maintaining a low-stimulus environment to help prevent exacerbation of withdrawal manifestations. Initiate neonatal abstinence syndrome (NAS) scoring is correct. The nurse should initiate NAS scoring to evaluate the severity of the newborn's withdrawal manifestations. The score obtained will be used to evaluate the need to titrate the prescription for the morphine dosage. The nurse should encourage the mother to continue to breastfeed on demand. Breastfeeding will assist to decrease manifestations of NAS in the newborn.
A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect?
Heart Rate 154/ min Respiratory rate 58/ min Weight 2,600 g (5lb 12 oz)
A nurse is performing a vaginal exam on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. MY ANSWER The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. The nurse should wrap the visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride solution. The nurse should apply oxygen to the client at 8 to 10 L/min via nonbreather mask. The nurse should place the client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to relieve the compression of the umbilical cord.
A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
Monitor FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
Perform Leopold maneuvers. MY ANSWER The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopoid maneuvers. Which of the following images indicates the first step of Leopoid maneuvers?
Picture of nurse palpating top of belly; where bottom is
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 for the newborn
Place the newborn skin to skin on the mothers chest. Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.
A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the development of preeclampsia
Pregestational diabetes mellitus MY ANSWER 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. Multifetal gestation increases a client's risk for the development of preeclampsia. Having a BMI greater than 30 increases a client's risk for the development of preeclampsia. A maternal age of younger than 19 or older than 40 increases the client's risk for the development of preeclampsia.
A nurse is creating a plan of care who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?
Protects the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Bathing the client within 12 hr following birth should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following birth. Ambulating the client within 24 hr following birth should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following birth. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Respiratory distress. Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
Schedule an ultrasound examination. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. There is currently no vaccine against fifth disease.
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?
Wipe eyes Wash Neck Cleanse skin around umbilical cord stump Wash legs and feet Clean diaper area. The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.
