Maternity / OB Exam 3 Practice Questions
A nurse is caring for newborn and calculation the Apgar score. At 1 min after delivery, the following findings are noted: 110 HR, slow, weak cry, some flexion of extremities, grimace in response to suctioning of the nares. body pink in color with blue extremities. Calculate the newborn's score.
6
A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a HR of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?
8
A nurse is providing discharge teaching for a non-lactating client. Which of the following instructions should the nurse include in the teaching? A. Wear a supportive bra continuously for first 72h B. Pump your breast every 4h to relieve discomfort C. Use breast shells throughout the day to decrease milk supply D. Apply warm compresses until milk suppression occurs.
A
A client gave birth 2 hours ago and the nurse notes the blood pressure is 60/50 mmHg. Which action first? A. Evaluate the firmness of the uterus B. initiate oxygen therapy by non-rebreather mask C. Administer oxytocin infusion D. obtain a type and crossmatch
A (This blood pressure can indicate postpartum hemorrhage so the nurse should see if there is a uterine atony. All of the other actions should be done but uterus assessment is first)
A client is reporting unrelieved episiotomy pain 8hr after delivery. Which of the following actions should the client's nurse take? A. Apply an ice pack to the perineum. B. Offer a warm sitz bath C. provide a squeeze bottle of antiseptic solution D. place a hot pack to the perineum
A. During the first 24 hr, ice packs and cool water sitz baths should be used. This should reduce edema and reduce discomfort.
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Ask another nurse to verify the heart rate. B. Document this as an expected finding. C. Call the provider to further assess the newborn. D. Prepare the newborn for transport to the NICU.
B
A nurse is completing discharge instructions for a new mother and her 2 day old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." B. "Your baby should wet 6 to 8 diapers per day." C. "Your baby should burp after each feeding." D. "Your baby should sleep at least 6 hours between feedings."
B
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. I will need to use contraception for 3 months before considering pregnancy. B. I need a second vaccination at my postpartum visit C. I was given the vaccine because my baby is O-positive D. I will be tested in 2 months to see if I have developed immunity
B
One the 2nd day postpartum following a cesarean birth, a client exhibits hypotension, dyspnea, hemoptysis, and chest pain. The nurse recognizes these as signs and symptoms of which of the following complications? A. Endometritis B. Pulmonary emboli C. Hypovolemia D. Atelectasis
B
Which of the following actions would the nurse include in the plan of care for a newborn receiving phototherapy? a. Keeping the newborn in the supine position b. Covering the newborn's eyes while under the phototherapy light c. Ensuring the newborn is covered and clothed d. Reducing the fluid intake to 6 ounces daily
B
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? A. Begin phototherapy. B. Initiate early feeding. C. Suction excess mucus with a bulb syringe. D. Prepare for an exchange blood transfusion.
B Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn's stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition
A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis? A. Swelling in both breasts B. Cracked and bleeding nipples C. Red and painful area in one breast D. A white patch on a nipple
C (Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral)
A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching? A. "I will breastfeed every 2 hours." B. "I will apply ice packs to my breasts after feeding." C. "I should apply hot packs to my breasts during feeding." D. "I should crush cabbage leaves and place them on my breasts."
C (The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.)
A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? A. I will decrease my daily fiber intake B. I'll make sure I reduce salt in my diet C. I'll eat more protein at each meal D. I will consume more vitamin D-rich foods
C (during lactation, client should consume about 25 g of additional protein per day.)
At birth, a newborn's assessment reveals the following: - Heart rate 140 - Loud crying - Some flexion of the extremities - Crying when the bulb syringe is introduced into the nares - Pink body with blue extremities The nurse would document the newborn's Apgar score as: A. 5 B. 6 C. 7 D. 8
D - Heart rate 140 (2) - Loud crying (2) - Some flexion of the extremities (1) - Crying when the bulb syringe is introduced into the nares (2) - Pink body with blue extremities (1)
Which of the following are risk factors for postpartum hemorrhage? Select all that apply A. Sixth pregnancy, fifth delivery B. Large for gestational age infant (LGA) C. Vaginal method of delivery D. Use of magnesium sulfate E. Use of oxytocin after delivery
A, B, D
Match the following types of heat loss with their potential cause 1. Convection 2. Conduction 3. Radiation 4. Evaporation A. being next to a wall with poor installation B. fans, open window C. stethoscope that's cold, cold bed D. cold bath
1. B 2. C 3. A 4. D
Match the following with the description 1. foramen ovale 2. ductus arteriosus 3. ductus venous A. a blood vessel in a fetus that bypasses pulmonary circulation by connecting the pulmonary artery directly to the ascending aorta B. connects the umbilical vein to the inferior vena cava C. connects the two atria in the fetal heart
1. C 2. A 3. B
Match the reflex with its description 1. sucking reflex 2. moro reflex 3. stepping reflex 4. tonic reflex 5. rooting reflex 6. Babinski reflex 7. palmar grasp 8. plantar grasp A. turning head to one side. Infant extends the arm and leg on that side and flexes the arm and leg on other side. B. "startle" Infant reflex where a baby will startle in response to a loud sound or sudden movement. C. Reflex in which a newborn fans out the toes when the sole of the foot is touched D. a neonatal reflex in which an infant lifts first one leg and then the other in a coordinated pattern like walking E. Touch sole of foot, toes curl downwards F. Reflex that causes a newborn to make sucking motions when a finger or nipple if placed in the mouth G. a baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple H. An infant reflex that occurs when something is placed in the infant's palm; the infant grasps the object.
1. F 2. B 3. D 4. A 5. G 6. C 7. H 8. E
A client who is breastfeeding is concerned their 3-day old infant is not getting enough to eat. Which of the following assessment findings indicates the infant is feeding well? A. The infant's stools are beginning to turn yellow B. The infant has not voided since birth C. The infant is nursing 4 times in 24 hours D. The client's breasts feel full after feedings
A
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make? A. "It sounds like you are feeling sad that things didn't go as planned." B. "At least you know you have a healthy baby." C. "Maybe next time you can have a vaginal delivery." D. "You can resume sexual relations sooner than if you had delivered vaginally."
A
A nurse is caring for a client who has DIC. Which of the following antepartum complications should the nurse understand is a risk factor for this? A. Preeclampsia B. Thrombophlebitis C. Placenta Previa D. Hyperemesis gravidarum
A
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
A
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? A. Staph aureus B. Chlamydia trachomatis C. Klebsiella Pneumonia D. Clostridium Perfringens
A
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. Increasing pulse and decreased BP B. Dizziness and increased RR C. Cool, clammy skin, and pale mucous membranes D. AMS and LOC
A
A nurse is caring for a newborn that's preterm and has respiratory distress syndrome. Which should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum Bilirubin D. Heart rate
A
A nurse is preparing to administer a vitamin K injection to a newborn. Which response should the nurse make to the parents regarding why the medication is given? A. It assists with blood clotting B. It promotes maturation of the bowel C. It is a preventative vaccine D. It provides immunity
A
A nurse is teaching a client who is postpartum and has a new Rx of an injection of Rh0 (D) immunoglobulin. Which of the following should be included in the teaching? A. It prevents the formation of Rh antibodies in mothers who are Rh negative. B. It destroys Rh antibodies in mothers who are Rh negative. C. It destroys Rh antibodies in newborns who are Rh positive. D. It prevents the formation of Rh antibodies in newborns who are Rh positive.
A
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking on the newborns back. Nurse should include what in the teaching? A. This is more commonly seen in infants with dark skin B. Finding indicating hyperbilirubinemia C. Forceps mark from an operative delivery D. Related to prolonged birth or trauma during delivery
A
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include? A. "Position the newborn at a 45-degree angle in the car seat." B. "Place the retainer clip across the newborn's abdomen." C. "Keep the car seat rear-facing until the newborn can sit unsupported." D. "Place the shoulder harness straps below the level of the newborn's armpits."
A
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate: a. Meconium aspiration, hypoglycemia, and dry, cracked skin. b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome. c. Golden yellow- to green stained-skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat. d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.
A
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."
A
L.K. is a G6 P5 client with severe preeclampsia on magnesium sulfate who has just given birth to a 39 week, 10 lb. 4 oz. male infant vaginally one hour ago. Upon assessment, the nurse notes the following: fundus 3cm above the umbilicus and boggy, large lochia rubra with small clots, T: 98.9, P: 110, R: 18, and BP 142/89. D5 ½ NS with 30 units of Pitocin is running at 75 mL/hr in addition to Magnesium sulfate running at 2g/hr (50 mL/hr). Blood type: A negative. GBS: positive; treated X2. Rubella: immune. Hepatitis B: nonreactive. What is the priority nursing action at this time? A. Massage the fundus B. Turn off the magnesium sulfate infusion C. Have the client void D. Check a hemoglobin and hematocrit
A
The most important nursing action in preventing neonatal infection is: a. Good handwashing. b. Isolation of infected infants. c. Separate gown protocol d. Standard Precautions.
A
The nurse is caring for an infant at birth. Thirty seconds after birth, the infant is dusky, gasping for breath and has a heart rate of 85. Which of the following actions would the nurse take next? A. Begin positive pressure ventilation B. Reposition the infant C. Start chest compressions D. Check the oxygen saturation
A
The nurse is reviewing the postpartum laboratory results for a client. The hemoglobin and hematocrit (H & H) are 8.8 and 27.9. Vital signs are: T: 98.2, P: 88, R: 18, and BP 132/85. Lochia is moderate red rubra; no clots. Which of the following orders would the nurse anticipate from the provider? A. Initiation of iron supplements B. 2 units of packed red blood cells (PRBCs) C. Methylergonovine maleate 0.2 mg IM now D. No new orders; this is a normal finding
A
carboprost is contraindicated in what group of patients? A. asthma B. hypotension C. cardiovascular disease D. gastroenteritis
A
What PPH conditions are considered medical emergencies that require immediate treatment? A. Inversion of the uterus and hypovolemic shock B. Hypotonic uterus and coagulopathies C. Subinvolution of the uterus and idiopathic thrombocytopenic purpura D. Uterine atony and disseminated intravascular coagulation
A Inversion of the uterus and hypovolemic shock are considered medical emergencies.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? A. Fundus firm to palpation B. Increase in blood pressure C. Increase in lochia D. Report of absent breast pain
A (Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.)
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."
A (Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.)
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. B. Notify the client's provider. C. Increase the frequency of fundal massage. D. Encourage the client to empty her bladder.
A (These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.)
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? A. Clear the respiratory tract. B. Dry the infant off and cover the head. C. Stimulate the infant to cry. D. Cut the umbilical cord.
A Clearing the airway of the infant is the first action the nurse should take immediately following delivery.
Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk. " C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk. " D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings. "
A Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method
A nurse is assessing a 37-weeks'-gestation newborn born by cesarean section, and now at 4 hours of age on room air. The newborn had no breathing problems at birth. The nurse notes the following signs: expiratory grunting, flaring of the nares, mild cyanosis, and respirations of 90 bpm. The newborn most likely is experiencing: a. Transient tachypnea of the newborn. b. Apnea of prematurity. c. Congenital diaphragmatic hernia. d. RDS (respiratory distress syndrome).
A In transient tachypnea of the newborn, tachypnea is usually present by 6 hours of age, with respiratory rates consistently higher than 60 bpm. It is more prevalent in cesarean-birth newborns who have not had the thoracic squeeze that occurs during vaginal birth and removes some of the lung fluid.
The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by: A. Subinvolution of the placental site B. Defective vascularity of the decidua C. Cervical lacerations D. Coagulation disorders
A Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments.
A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? A. "My baby will be placed under special lights if the test result is positive." B. "My baby needs to be on formula or breast milk before the test can be done." C. "This test checks for a genetic disorder that can be managed by diet." D. "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up."
A Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? A. Respiratory distress B. Hypothermia C. Accidental lacerations D. Acrocyanosis.
A Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress.
The perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: A. Uterine atony B. Uterine inversion C. Vaginal hematoma D. Vaginal laceration
A Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage.
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress B. Shivering C. Basal metabolic rate reduction D. Brown fat production
A When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.
An RN is reviewing the lab findings of a 24-hour newborn. Which of the following findings should the RN report to the provider? A. hemoglobin of 12 B. platelet count of 200 K C. bilirubin of 4 D. glucose of 50
A expected range is 14-24
A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility B. Physiologic jaundice C. Absence of vitamin K D. Maternal cocaine use
A most common form of pathologic jaundice; appears within the 1st 24 hrs of life. Physiologic jaundice appears after 24 hrs.
An RN is caring for a newborn who is premature at 30 weeks. Which of the following findings should the RN expect? A. abundant lanugo B. good flexion C. heel creases covering the bottom of the feet D. dry, parchment-like skin
A preterm newborns: - hypotonic - few heal creases - abundant vernix
An RN is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. maternal drug use C. hyaline membrane disease D. meconium aspiration
A relieves respiratory depression from acute narcotic toxicity the use of naloxone in a newborn exposed to narcotics during pregnancy could cause immediate withdrawal symptoms
An RN is assessing a 2-day-old newborn and notes and egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the RN provide to the mother when she asks about this finding? A. This is called cephalohematoma, and it will resolve in 3-6 weeks without treatment. B. This is caput succedaneum, and it will resolve on its own within 3-4 days C. The provider might drain this area with a syringe D. This appearance is expected at birth, so you don't need to worry.
A why not B? = extends across suture lines and resolves within 3-4 days
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30 min period. Which of the following is the priority nursing intervention at this time? A. Palpate the client's uterine fundus. B. Assist the client on a bedpan to urinate. C. Prepare to administer oxytocic medication. D. Increase the client's fluid intake.
A (Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client's fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone.)
A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of LR with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include BP 146/95, pulse 80, RR 18. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? A. Methylergonovine 0.2 mg IM now. B. Insert an indwelling urinary catheter. C. Administer oxygen by nonrebreather mask at 5 L/min. D. Obtain laboratory study of prothrombin and partial thromboplastin time.
A (Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification.)
A nurse is caring for a client who is experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? A. At the level of the umbilicus B. 2 cm above the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus
A (Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day. The uterus would be palpated at a position between the umbilicus and symphysis pubis in a client who is approximately 1 week postpartum.)
A nurse is discussing RF for UTI with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? Select all that apply A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTI E. Vaginal birth
A, B, C, D
A nurse monitors all newborns in the NICU for hypoglycemia. Which manifestations could indicate hypoglycemia in one of the babies? (SATA) A. Apneic episodes B. None (asymptomatic) C. Eye rolling D. Lethargy E. Palmar sweating
A, B, C, D
A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? Select all that apply A. Blot the perineal area dry after cleansing. B. Clean the perineal area from front to back. C. Perform hand hygiene before and after voiding. D. Apply ice packs to the perineal area several times daily. E. Wash the perineal area using a squeeze bottle of warm water after each voiding.
A, B, C, E (Ice packs may be applied to the perineal area for the first 24 to 48 hr to decrease edema and to provide an anesthetic effect. This would not be indicated after that time, nor does it provide any preventative benefits from infection)
A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which manifestation could indicate postpartum depression? Select all that apply A. Fatigue B. Insomnia C. Euphoria D. Flat Affect E. Delusions
A, B, D
A nurse is called to the birthing room to assist the assessment of a newborn at 32 weeks gestation. Weight is 1,100g. Which of the following are expected findings? Select all that apply A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face
A, C, D
A nurse on the postpartum unit is assessing a client who is being admitted with a suspected DVT. Which of the following clinical findings should the nurse expect? (Select all) A. Calf tenderness to palpation B. Mottling of affected extremity C. Elevated temperature D. Area of warmth E. Report of nausea
A, C, D
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? Select all that apply A. Document fundal height. B. Massage a firm fundus. C. Observe the lochia during palpation of fundus. D. Determine whether the fundus is midline. E. Administer methylergonovine maleate if uterus is boggy.
A, C, D, E
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (Select all) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments
A, C, E
A nurse is providing education to a client who is 2 hours postpartum and has perineal laceration. Which of the following information should the nurse include? (Select all) A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back and forth motion E. Apply cold or ice packs to perineum
A, C, E
A nurse is reviewing contraindications for circumcision with a new nurse. Which of the following are contraindications? Select all that apply A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias
A, C, E
A baby was born 4 days ago at 34 weeks gestation and is receiving phototherapy for neonatal jaundice. The baby has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. What are the nurses priority nursing interventions? (SATA) A. Assess the baby's temperature to check for hypothermia. B. Check to make sure the infant's face mask stays in place. C. Educate the mother to feed the child every 2 hours. D. Verify laboratory results to check for hypoglycemia. E. Verify laboratory results to check for hypomagnesemia.
A, D
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? A. Hepatitis B Immunization B. Haemophilus influenzae type B immunization (Hib) C. Lidocaine gel to the umbilical stump D. Vitamin K Injection E. Antibiotic ointment to both eyes
A, D, E
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care (Select all that apply) A. I'll expect the plastic ring to fall off by itself within a week B. I'll apply petroleum jelly to his penis with diaper changes C. I'll wash his penis with warm water and mild soap each day D. I'll call the doctor if I see any bleeding E. I'll make sure his diaper is loose in the front
A, D, E
A new mother wants to nurse her infant only 5 minutes at each breast to avoid sore nipples. Choose the appropriate teaching. a. Keeping early feedings short lessens nipple trauma and helps toughen nipples. b. Very short feedings reduce hindmilk and may interfere with the infant's weight gain. c. Limiting time at the breast does not reduce sore nipples but does reduce engorgement. d. Delay in the transition from colostrum to true milk will result from this practice.
B
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed. B. Ask the client if they have thoughts of harming themselves or their infant C. Monitor the infant for indications of failure to thrive D. Review the client's medical record for a history of bipolar disorder.
B
A nurse is caring for a newborn who was born at 38 weeks, weighs 3,200g, and in the 60th percentile for weight. Based on weigh and gestational age, the nurse should classify the neonate as? A. Low birth weight B. Appropriate for Gestational Age C. Small for gestational age D. Large for gestational age
B
A nurse is caring for a newborn. Which activity indicates ready to feed? A. Spits to clear up mucus B. Attempts to place hand in mouth C. turns head to sounds D. lies quietly with eyes open
B
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended to a third-degree laceration B. A client who does not wash their hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation D. A client who has a c-section incision that is well-approximated with no drainage
B
A nurse is teaching a new licensed nurse about neonatal abstinence syndrome. Which statement indicates understanding? A. Newborn will have decreased muscle tone B. Newborn will have continuous high-pitched cry C. Newborn will sleep for 2-3h after feeding D. Newborn will have mild tremors when disturbed
B
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? A. "I will place my baby on his stomach when he is sleeping." B. "I should remove extra blankets from my baby's crib." C. "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." D. "I should place my baby's crib next to the heater to keep him warm during the winter."
B
A nurse on the postpartum unit is caring for 4 clients. Which of the following clients should the nurse recognize as the greatest risk for development of postpartum infection? A. client who experienced a precipitous labor less than 3h B. Client who had PROM and prolonged labor C. client who delivered LGA infant D. Client with boggy uterus that was not well contracted
B
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.
B
The nurse is caring for a postpartum client who has chosen to bottle feed. Which of the following points will the nurse include in teaching to promote lactation suppression? A. Apply warm compresses to the breasts B. Wear a tight-fitting bra C. Pump the breasts only bid D. Increase fluid intake
B
The nurse is educating a Graduate Nurse on appropriate fundal massage technique. Which of the following statements by the Graduate Nurse indicates understanding of correct fundal massage technique? A. Placing continuous two-handed pressure on the uterus until the bleeding stops B. One hand anchors the lower uterine segment while the other hand massages the fundus C. Placing one hand firmly on the fundus until clots are expressed D. Applying bimanual pressure to the uterus
B
Which of the following would not cause uterine atony? A. terbutaline B. oxytocin C. magnesium sulfate D. general anesthesia
B
A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in". Which of the following responses should the nurse make? A. Within 2 days B. In 3-5 days C. In 6-8 days D. In about 10 days
B (By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.)
A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? A. Saturated perineal pad in 30 min B. Deep tendon reflexes 4+ C. Fundus at level of umbilicus D. Approximated edges of episiotomy
B (Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding.)
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? A. Assist the family to identify prior use of positive coping skills in family crises. B. Ask the client if she has considered harming her newborn. C. Anticipate a prescription by the provider for an antidepressant. D. Reinforce postpartum and newborn care discharge teaching.
B (When using the nursing process in caring for a client, the first action should focus on assessment of the client's mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn.)
An RN is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the RN instruct the guardian to avoid using antimicrobial agents on the cord? A. they can cause increased pain from the cord B. they can cause delayed cord separation C. they can cause swelling of the surrounding tissue D. they can cause skin discoloration
B - tissue is no longer functioning = cannot cause pain - swelling around the cord would indicate an infection (opposite of antimicrobial)
A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? A. Platelets 200,000/mm3 B. Bilirubin 19 mg/dL C. Blood glucose 45 mg/dL D. Hemoglobin 22 g/dL
B A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice
The nurse is preparing to initiate bottle feeding of a preterm infant. The nurse's assessment reveals: • HR: 136 bpm • RR: 68 breaths/min • Temp: 97.9 ˚ F axillary • TCB: 5.4 Which of the following actions would be appropriate for the nurse to take? A. Begin bottle feeding the infant B. Withhold the feeding and notify the physician C. Recheck the temperature under the other arm D. Insert a nasogastric (NG) tube to administer the feeding
B RR is way too high before a feeding, and feedings increase work of RR
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? A. 22/min B. 48/min C. 100/min D. 110/min
B The expected reference range for a newborn's resting respiratory rate is 30 to 60/min.
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? A. Suction the nose with a bulb syringe. B. suction the mouth with a bulb syringe. C. Use a suction catheter with low negative pressure. D. Turn the newborn on his side.
B The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three finger breadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? A. The client is exhibiting early indications of mastitis. B. Additional interventions are not indicated at this time. C. Application of a heating pad to the breasts is indicated. D. The client should be advised to remove her nursing bra.
B (For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range)
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? A. "You need to take pain medications so you are more comfortable." B. "We can time your pain medication so that you have an hour or two before the next feeding." C. "All medications are found in breast milk to some extent." D. "You have the option of not taking pain medication if you are concerned."
B This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? Select all that apply A. Paranoia that their infant will be harmed B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a parent D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a parent
B, C, D, E
A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F. Which of the following could explain this assessment finding? A. This is a normal temperature for a preterm neonate. B. Axillary temperatures are not valid for preterm babies. C. The supply of brown adipose tissue is incomplete. D. Conduction heat loss is pronounced in the baby.
C
A newborn was not completely dried after brith. Placing them at risk for which heat loss? A. Conduction B. Convection C. Evaporation D. Radiation
C
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks at you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "the best way to determine if your baby can hear is to clap your hands loudly and see if she startles."
C
A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statement is a therapeutic response by the nurse? A. "I will call your primary care provider to report your concerns." B. "I will take your baby to the nursery for further examination." C. "This occurs because newborns lack muscle control to regulate eye movement." D. "This is a concern, but strabismus is easily treated with patching."
C
A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. What action should nurse implement? A. Apply gelfoam powder to site B. Place newborn in prone position C. Apply petroleum gauze to site D. Avoid changing the diaper until first voiding
C
A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days
C
A nurse is caring for an infant who has high bilirubin levels and is receiving phototherapy. What is a priority finding? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash
C
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. which medication should the nurse anticipate? A. ofloxacin B. nystatin C. erythromycin D. cerftriaxone
C
A nurse is providing discharge instructions to a postpartum client following a c-section. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. Sit ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches
C
A nurse is providing discharge teaching regarding circumcision care. What statement indicated understanding? A. Circumcision will heal in a couple days B. I should remove the yellow mucus that will form C. I will clean the penis with each diaper change D. I will give him a tub bath within a couple of days
C
A nurse is reviewing car seat safety. What indicates understanding of car seat position? A. Front seat, rear facing B. Front seat, forward facing C. Back seat, rear facing D. Back seat, forward facing
C
A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? A. ask the patient to state their full name B. look at the name on the bassinet C. Match the parents ID bands with the newborn's D. Compare name on bassinet and room number
C
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. Limit amount of time infant is on each breast B. Nurse the infant only on the unaffected breast until resolved C. Completely empty each breast at feeding or use a pump D. Wear a tight fitting bra until lactation has stopped
C
A nurse is teaching a group of new parents about proper techniques for bottle feeding. What instructions should the nurse provide? A. Burp newborn at the end of feeding B. Hold newborn close in supine position C. Keep nipple full of formula throughout feeding D. Refrigerate any unused formula
C
A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statement by the parent indicates understanding of the teaching? A. "I should start solid foods when my baby is 3 months old." B. "I should introduce cow's milk when my baby is 9 months old." C. "I should wait to give fruit juice until my baby is 6 months of age." D. "I should wait to begin fluoride supplements until my baby is 4 months of age."
C
A nurse on the l&d unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placing the newborn on a warm surface B. Preventing air drafts C. Drying the newborn's skin thoroughly D. Maintaining ambient room temperature at 24° C (75° F)
C
A postpartum client appears very pale and states they are bleeding heavily. Which of the following actions would the nurse take first? A. Call the provider immediately B. Administer Methylergonovine 0.2mg IM C. Assess the uterine fundus and determine when the client voided last D. Reassure the client this a normal postpartum finding
C
An RN is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the RN identify as a potential complication of oxygen therapy? A. atelectasis B. interstitial emphysema C. retinopathy D. necrotizing enterocolitis
C
An RN is testing reflexes of a newborn to assess neurological maturity. Which of the following reflexed is the RN assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic D. Babinkski
C
An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. Birth injury. b. Hypocalcemia. c. Hypoglycemia d. Seizures.
C
During ambulation to the bathroom a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse find the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being. A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow
C
For clinical purposes, preterm and post-term infants are defined as: a. Preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA). b. Post-term after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA. c. Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth. d. Preterm, SGA before 38 to 40 weeks, and post-term, LGA beyond 40 to 42 weeks.
C
In planning care for a polycythemic infant, the nurse would know that common symptoms of polycythemia include: a. Apnea, hypotension, and hyperthermia. b. Bradycardia, hypotension, and leukopenia. c. Tachycardia, respiratory distress, and hyperbilirubinemia. d. Orthopnea, tachypnea, and hyperbilirubinemia.
C
Infants of mothers with diabetes (IDMs) are at higher risk for developing: a. Anemia. b. Hyponatremia. c. Respiratory distress syndrome. d. Sepsis.
C
The client's fundus is firm at midline at the level of the umbilicus. Moderate lochia rubra is present. The nurse notes in the chart the patient had a fourth degree laceration. Upon assessment, the nurse notes the wound edges are well-approximated, no redness, purulent drainage, ecchymosis, or active bleeding is noted. The labia are swollen and several hemorrhoids are present. What is the priority nursing consideration for this client at this time? A. Breastfeeding success B. Client perception of body image C. Client pain level D. Potential for constipation
C
The nurse is admitting an infant of an individual with diabetes during pregnancy to the nursery. At 1 hour of age, the nurse notes the infant to have poor muscle tone and an axillary temperature of 97.5 F. Which of the following actions would be appropriate for the nurse to take? A. Begin oxygen via nasal cannula B. Feed the infant C. Check the blood glucose level D. Draw a serum bilirubin
C
The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: a. Is adopted from classical British nursing traditions. b. Helps infants with motor and central nervous system impairment. c. Helps infants to interact directly with their parents and enhances their temperature regulation. d. Gets infants ready for breastfeeding.
C
The nurse would teach a client prescribed simethicone to avoid which substance? A. Over-the-counter antacids B. Histamine2-receptor antagonists C. Carbonated beverages D. Milk and dairy products
C
The oncoming nurse is reviewing a client's labor and delivery data and notes that mom is type A negative and the infant is type A positive. Which of the following actions are appropriate for the nurse to take? A. Inform the client they have ABO incompatibility B. Monitor the infant closely for the development of hypobilirubinemia C. Call the provider and obtain an order for RhoGAM D. Administer the MMR vaccine
C
When assessing a term newborn at 6 hours old, the nurse auscultates bowel sounds and documents the recent passage of meconium stool. These findings would indicate which of the following? A. Abnormal gastrointestinal newborn transition and needs to be reported B. An intestinal anomaly that needs immediate surgery C. A patent anus with no bowel obstruction and normal peristalsis D. A malabsorption syndrome resulting in fatty stools
C
Which of following education about sexual activity would the nurse include in postpartum teaching? A. Interest in sexual activity may increase due to hormonal fluctuations B. Lubricants are unnecessary due to the increased vaginal mucus C. Sexual intercourse should be avoided until vaginal bleeding has ceased D. Natural family planning is the best method to avoid pregnancy in the postpartum period
C
methylergonovine is contraindicated in what group of patients? A. asthma B. hypotension C. cardiovascular disease D. gastroenteritis
C
An RN is assessing a client who is postpartum following a vacuum-assisted birth. Which of the following findings should the RN monitor to identify a cervical laceration? A. continuous lochia flow and a flaccid uterus B. report of increasing pain and pressure in the perineal area C. slow trickle of bright vaginal bleeding with a firm fundus D. gush of rubra lochia when the uterus is massaged
C A. would likely be retained placental fragments B. vulvar hematoma
An RN is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The RN should plan to administer which of the following medications? A. terbutaline B. magnesium sulfate C. oxytocin D. methylergonovine
C A. for preterm uterine relaxation B. tocolytic for seizure management D. uterotonic with adverse SE of HTN (cannot give to preeclamptic patients)
A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? A. Moderate amount of dark red lochia with a bloody odor B. A localized area of breast tenderness C. Pelvic pain D. Hematuria
C (Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.)
A postpartum RN is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the RN take? A. prepare to initiate a warm water sitz bath for the client's perineum B. encourage the client to sit on a soft pillow C. apply cold ice packs to the client's perineum D. administer an acetaminophen suppository rectally
C cold ice packs are used on the perineum to decrease edema, pain and discomfort warm sitz baths are appropriate after the first 24 hours postpartum, and a cold bath is recommended within the first 24 hours
An RN is assessing a newborn. Which of the following findings should the RN report to the provider? A. RR of 52/min B. weight of 2500 grams C. head circumference of 28 cm D. blood glucose of 48 mg/dL
C expected head circumference = 32-36.8 cm, so this would indicate microcephaly
A nurse is assessing a newborn. For which of the following findings should the RN notify the provider? A. HR of 136/minute B. acrocyanosis C. mottling D. RR of 60/min
C mottling is an indication of hypothermia or respiratory distress
A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statement by the client as an indication of inhibition of parental attachment? A. "He's got my husband's nose, that's for sure." B. "I don't need a baby bath demonstration. I know how to do it." C. "I wish he had more hair. I will keep a hat on his head until he grows some." D. "Do you think you could keep him in the nursery for the next feeding so I can get
C (This client statement expresses disappointment in the newborn's appearance and a need to hide what the client perceives as an undesirable feature. This is an indication of inhibited parental attachment.)
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? A. Flex her knee while resting B. Massage the area C. Elevate her leg D. Apply a cold compress
C (encourages venous return and relieves pain. Client should also apply moist heat to the affected area)
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? Select all that apply A. Expiratory grunting B. Inspiratory nasal flaring C. Apena for 10sec periods D. Obligatory nose breathing E. Crackles and wheezing
C, D
A nurse is reviewing formula preparation with parents who plan to bottle feed their newborn. What information should the nurse include? Select all that apply A. use a disinfectant wipe to clean lid of formula can B. store prepared formula in fridge for up to 72h C. Place used bottles in dishwasher D. Check nipples for appropriate flow of formula E. Use tap water to dilute concentrated formula
C, D, E
A nurse is reviewing discharge teaching with a client who has a UTI. Which of the following statements indicates understanding? Select all that apply A. I will perform perineal care and apply a perineal pad in a back to front direction B. I will drink grape juice to make my urine more acidic C. I will drink large amounts of fluids to flush bacteria from my urinary tract D. I will go back to breastfeeding after I have finished the abx E. I will take tylenol for any discomfort
C, E
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
D
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. Hand the parent the newborn, and suggest that they change the diaper B. Ask the parent why they are so anxious and nervous C. Tell the parent they will grow accustomed to the newborn D. Provide education about infant care when the parent is present
D
A nurse is assess a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. postpartum fatigue B. postpartum psychosis C. Letting Go phase D. postpartum blues
D
A nurse is caring for a client 42 weeks gestation and in labor. She asks the nurse what to expect because baby is post-mature. What should the nurse say? A. excess body fat B. flat areola without breast buds C. heels move easily to ears D. skin will have a leathery appearance
D
A nurse is caring for a newborn immediately following birth. Which of the following is highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving Vitamin K injections D. Covering newborn's head with a cap
D
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This is a characteristic of? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls
D
A nurse is giving instructions to a parent about how to breastfeed. Which action indicates understanding? A. Parent puts a few drops of water on their nipple before feeding B. Parent gently removes their nipple from the infant's mouth to break the suction C. When ready to feed, parent strokes the newborn's neck with a finger D. When latched on, the infant's nose, cheek and chin are touching the breast
D
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Apply cold compress B. Massage extremity C. Allow client to ambulate D. Measure leg circumferences
D
A nurse is reviewing breastfeeding positions with the parents. which position should the nurse discuss? A. Over the shoulder B. Supine C. Chin Supported D. Cradle
D
A nurse is reviewing care of the umbilical cord with the parent. Which instructions should be included? A. Cover cord with small square gauze B. Trickle clean water over cord with each diaper change C. Apply hydrogen peroxide to cord twice a day D. Keep diaper folded below the cord
D
A postpartum RN is providing care for a client breastfeeding and has a perineal hematoma. The RN should recommend which of the following breastfeeding positions? A. cross-cradle B. across-the-lap C. clutch hold D. side lying
D
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. Suffering from sleep or wakeful apnea. b. Experiencing severe swings in blood pressure. c. Trying to maintain a neutral thermal environment. d. Breathing in a respiratory pattern common to premature infants.
D
When a woman develops gestational diabetes it is during a time in the pregnancy when insulin sensitivity is _____________. This is majorly influenced by hormones such as estrogen, progesterone, _______________ and _______________. A. high; prolactin and human chorionic gonadotropin (hCG) B. low; estriol and human placental lactogen (hPL) C. high; human chorionic gonadotropin (hCG) and cortisol D. low; human placental lactogen (hPL) and cortisol
D
Which of the following medications is given via rectal suppository? A. oxytocin B. methylergonovine C. carboprost tromethamine D. misoprostol E. tranexamic acid (TXA)
D
A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest? A. Apply mineral oil to the nipples between feedings. B. Keep the nipples covered between breastfeeding sessions. C. Increase the length of time between feedings. D. Change the newborn's position on the nipples with each feeding.
D (client should expose sore nipples to air as much as possible and decreasing frequency of feedings does not prevent sore nipples)
A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make? A. you might want to offer water supplements between feedings. B. this might be related to your baby having 3 stools a day C. it is due to the newborns loss of the influence of the maternal hormones D. the cause might be too short or infrequent feedings
D Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal factors such as breasts not emptying, stress, and fatigue.
A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia PCA) pump following a C-section. Which of the following findings should the RN report to the provider? A. RR of 14/min B. Temperature of 37.8 C. Dizziness upon rising D. UO of 20 mL/hr
D opioids can cause urinary retention
An RN is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the RN make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains estrogen only is available for use while breastfeeding." C. "Condoms are the only method of contraception that is appropriate while breastfeeding." D. "A progestin-only pill or injection is available for use while breastfeeding."
D progestin-only injections, implants and pills are acceptable options for clients who are breastfeeding estrogen-containing birth control methods are not recommended because they could possibly inhibit breast milk production and supply
An RN is teaching a client who is breastfeeding about strategies to prevent mastitis. Which of the following should the RN include? A. take a herbal galactagogue B. gradually increase the time between feedings C. wear and underwire bra D. use your finger to release suction after feeding
D releasing the newborn's grasp with a finger before removing the newborn from the breast helps prevent nipple injuries (they lead to mastitis)
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? A. Perform a sharp hand clap near the infant. B. the newborn vertically allowing one foot to touch the table surface. C. Place a finger at the base of the newborn's toes. D. Turn the newborn's head quickly to one side.
A To elicit the Moro reflex, the nurse performs a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position.
A nurse is caring for a client who is one day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those family members E. Interprets the newborn's behavior as meaningful and a way of expressing needs.
A, C
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. The client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? A. Come back later when the client is more cooperative B. Give client time to express feelings C. Tell the client they need to be quiet so the assessment can be completed D. Redirect the clients focus so they will become quiet
B
A client is to be discharged this morning with their infant. Discharge teaching would include all the following except: A. Continue taking your prenatal vitamins B. Avoid using tampons, douching, or intercourse for 7-10 days C. Call your provider for any fever, significant increase in vaginal bleeding, or foul-smelling lochia D. Eat a well-balanced diet and increase your fluid intake
B
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A. Moderate lochia rubra B. Fundus three fingerbreadths above the umbilicus C. Moderate swelling of the labia D. Blood pressure 130/84 mm Hg
B
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? A. Caput succedaneum B. Cephalhematoma C. Molding D. Pilonidal dimple
B
A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? A. Babinski B. Rooting C. Moro D. Stepping
B
A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? A. I am likely to have a fever the first week I am home B. I will resume taking my prenatal vitamins C. I will call my provider if I have discharge from my incision D. I should not have unrelieved pain in my abdomen E. I will rest in a recliner until my incision is healed
B, C, D
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? A. Wash the cord daily with mild soap and water. B. Cover the cord with the diaper. C. Apply petroleum jelly to the cord stump. D. Give a sponge bath until the cord stump falls off.
D Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infection B. Retained placental fragments C. Thrombophlebitis D. Uterine atony
D A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? A. Obtain blood glucose by heel stick. B. Initiate phototherapy. C. Monitor the newborn's blood pressure. D. Place the newborn in a radiant warmer.
A
A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse? A. Blood pressure 100/70 mm Hg B. Headache pain rated a 6 on a scale of 0 to 10 C. Respiratory rate 10/min D. Urinary output 30 mL/hr
C
A nurse is conducting a home visit for a client who is one week postpartum and breastfeeding. The client report breast engorgement. Which of the following recommendations should the nurse make? A. Apply cold compresses between feedings B. Take a warm shower right after feedings C. Apply breast milk to the nipples and allow them to air dry D. use the various infant positions for feedings.
A
A nurse is performing a fundal assessment for a client who is 3 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12cm with lochia that is bright red and contains small clots. Which of the following should the nurse document? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubrua D. Scant lochia serosa
A
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Deltoid
A
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of uterine atony. A. Poor involution B. Urinary retention C. Hemorrhage D. Infection
B
A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? A. Fundus soft, 1 cm to the right of the umbilicus B. Fundus firm, at the level of the umbilicus C. Fundus present, to the left of the umbilicus D. Fundus soft, 2 cm above the umbilicus
B
A nurse is caring for a client who is 2 days postpartum. The client states "My 4 year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. Your son was probably not ready for toilet training and should wear training pants B. Your son is showing an adverse sibling response C. Your son may need counseling D. You should try sending your son to preschool to resolve the behavior
B
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? A. Sternal notch B. Nipple line C. Xiphoid process D. Fifth intercostal space
B
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse? A. "You may carry your grandchild to the room." B. "You can push the baby to the room in a wheeled bassinet." C. "Have the mother call and I will take the baby to the room." D. "If you show me your photo identification, you can take the infant."
C
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. Scant, non odorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipples with cracks and fissures D. Decreased response to sexual activities.
C
A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is a priority action by the nurse? A. Encourage parents to touch and explore neonates features B. Limit noise and interruption in the delivery room C. Place the neonate at the clients breast D. Position the neonate skin-to-skin on the client's chest
D
A nurse is planning care for a client who is 2 hrs postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? A. Apply warm, moist heat to the client's lower extremities. B. Massage the client's posterior lower legs. C. Place pillows under the client's knees when resting in bed. D. Have the client ambulate.
D
A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction? A. "I will keep my baby's head elevated while he is feeding." B. "I will allow my baby to burp several times during each feeding." C. "My baby will have soft, formed brown stools." D. "I will tip the nipple so air is present as my baby sucks."
D
Which of the following instructions would the nurse provide regarding self care while breastfeeding? A. Birth control measures are unnecessary while breastfeeding B. Soap should be used to cleanse the breasts BID C. Prenatal vitamins should be discontinued D. Additional PO fluids are encouraged
D
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A. A newborn who is 24 hr post-delivery and has not voided. B. A newborn who is 18 hr post-delivery and has acrocyanosis C. A newborn who is 24 hr post-delivery and has not passed meconium D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)
D Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.
A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide? A. "I'll feed him today. Maybe tomorrow you can try it." B. "Oh, this isn't difficult. You'll be fine doing this." C. "You can learn to feed him; I wasn't comfortable the first time I fed a baby either." D. "Feeding an infant can feel a little intimidating at first, but I'll stay and help you."
D (The nurse, while recognizing and acknowledging the client's apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence.)
Client calls out to the nurses' station reporting that their newborn still won't eat. The client is an LGA male gender assigned at birth neonate born 8 hours ago at 36 weeks gestation. Apgars were 8/8. The pregnancy was complicated by insulin dependent gestational diabetes. Blood glucose since birth have been 41, 46, and most recent 44. Maternal blood type A-, neonatal blood type A+. The neonate is breastfeeding and last ate 4 hours ago. Vital signs: T 97.4, P 142, RR 46. The neonate is sleepy, jittery, and rooting reflex is unable to be elicited. LCTA. Skin is slightly cool to touch, pink with acrocyanosis on the hands and feet. No void or stool since birth. The client is at highest risk for developing: A. cold stress B. kernicterus C. severe hypoglycemia as evidenced by the client's: A. vital signs B. blood glucose levels C. blood type D. neurological assessment
The client is at highest risk for developing: A. cold stress B. kernicterus C. severe hypoglycemia as evidenced by the client's: A. vital signs B. blood glucose levels C. blood type D. neurological assessment
