PN Learning System Maternal Newborn Final Quiz

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make?

"A weight gain of about 25 to 35 pounds is good." A weight gain of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.

A nurse is reinforcing discharge instructions with a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?

"Do not become pregnant for at least 1 year." Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.

A nurse is reinforcing teaching with a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching?

"I should press the button on the hand held marker when my baby moves." The purpose of a nonstress test is to assess fetal well-being. The client should press the button on the hand held marker when she feels fetal movement.

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching?

"I should replace my diaphragm every 2 years." The diaphragm is flexible rubber cap that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years.

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

"I will warm the bottle of formula by placing it in a pan of hot water." The nurse should instruct the client to warm the bottle of formula by placing it in a pan of hot water and to test the temperature of the formula by dropping a couple drops on the wrist. A bottle of formula should never be placed in the microwave to warm.

A nurse is caring for a client wo is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the nurse's priority?

"My heart feels as if it is racing." The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent.

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make?

"These feelings are common for expectant fathers in early pregnancy." The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

A nurse is caring for a client who is at 8 weeks of gestation with twins and is primigravida. The client states that even through she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make?

"These feelings are normal at the beginning of pregnancy." This client needs reassurance that these feelings are normal and there is no reason for concern.

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan?

"You and your partner need to take the medication and use a condom during intercourse until cultures are negative." Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and woman can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated.

A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide to the client?

"You should eat some crackers before rising from bed in the morning." Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include?

"You should use fluoride-based toothpaste to prevent dental caries." Nausea during pregnancy can lead to poor oral hygiene and inflammation of the gingival tissue, which can lead to dental caries. The nurse should instruct the client to use a fluoride-based toothpaste during pregnancy.

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching?

"You will have a cesarean birth prior to the onset of labor." Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.

A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following information should the nurse include?

"Your baby should have bursts of 15 sucks or swallows at a time." A newborn will exhibit bursts of 15 to 20 sucks or swallows at a time. This is an indication that breastfeeding is effective.

A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider?

A 12-hr-old newborn who has a heart rate of 70/min while sleeping An average heart rate for a newborn is 80 to 100/min while sleeping. A newborn's heart rate can increase to 180/min during episodes of crying. A heart rate less than 80/min is bradycardia and should be reported to the provider.

A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia?

A newborn who is large for gestational age Large for gestational age (LGA) newborns are those whose weight is at or above the 90th percentile. One of the most common etiologies of LGA newborns is the diabetic mother. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.

A nurse is collecting data on a newborn who was born at 43 weeks of gestation. Which of the following findings should the nurse expect?

Absent vernix Vernix is a white substance that covers the skin of the newborn starting at 18 weeks of gestation. Vernix keeps the skin soft and provides a protective barrier for the newborn. Postterm newborns will not have vernix.

A nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for use of this medication?

Active genital herpes The use oxytocin is contraindicated for clients who have active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Nagele's rule, which of the following is the client's expected date of birth (EDB)?

April 15 According to Nagele's rule, the EDB is predicted by counting back 3 months from the first day of the last menstrual period and adding 7 days.

A nurse is collecting data from a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take?

Ask the client when she last voided. Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at midline. A deviated, firm fundus usually indicates a full bladder. The nurse should assist the client to void.

A nurse is assisting with the plan of care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?

At 28 weeks of gestation The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and blocks maternal antibody production.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take?

Continue to routinely monitor the newborn. This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse administers betamethasone to a client who is at 33 weeks of gestation to simulate fetal lung maturity. When assisting with the plan of care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication?

Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. It is important to check the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable.

A nurse is assisting in the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care?

Ensure the newborn's eyes are closed before applying the eye shield. Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?

Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.

A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn?

Frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation in order to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.

A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain?

Group B streptococcus B-hemolytic culture The nurse should obtain a vaginal/anal group B streptococcus B-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS.

A nurse is contributing to the plan of care for a client who plans to formula feed her newborn. Which of the following actions should the nurse include in the plan?

Have the client place ice packs on her breasts four times per day. Engorgement can occur in the non-breastfeeding client. For some clients, it is uncomfortable, and occasionally painful. Ice application to the breasts for 15 to 20 min, four times per day for 5 days, avoiding breast stimulation, and keeping warm water off the breasts during showering are effective methods to reduce milk production and suppress lactation.

A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions should the nurse take?

Initiate a latex free environment. Newborns who have myelomeningocele are prone to latex allergies. The nurse should take special precautions to avoid direct or indirect contact with latex products.

A nurse in an antepartum client answers a phone call from a client wo is at 37 weeks of gestation reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take?

Instruct the client about vena cava syndrome and measures to prevent it. This is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side-lying position promotes uterine perfusion and fetoplacental oxygenation.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first?

Massage the fundus The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. Therefore, the greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first.

A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device?

Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or have a history of ectopic pregnancy.

A nurse is assisting with caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority?

Nonreactive stress test A nonstress test measures fetal heart rate (FHR) accelerations with normal movement. A fetal acceleration is a positive sign. It is present when the FHR increases 15/min and lasts 15 seconds. In a nonreactive nonstress test, there are no accelerations. The absence of FHR accelerations suggests that the fetus may be going into distress.

A nurse is collecting data for a newborn who is 12 hr old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take?

Obtain a stat prescription for a bilirubin level. Jaundice in the first 24 hr of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?

Pelvic inflammatory disease An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus, and the placenta and fetus begin to develop there. The most common site is within a fallopian tube, but ectopic pregnancies can occasionally occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, pelvic inflammatory disease (PID) places the client at risk for an ectopic pregnancy.

A nurse is assisting with the care of a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy?

Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. Retinopathy is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness.

A nurse is collecting data on a client who is at 8 weeks of gestation. Which of the following findings should the nurse report to the provider?

Small amount of brown vaginal discharge A small amount of brown vaginal discharge can be a warning sign of an ectopic pregnancy. An ectopic pregnancy is where the fertilized ovum is implanted outside of the uterus. The nurse should report this finding to the provider.

A nurse is preparing a client who is pregnant for an ultrasound. Which of the following information is the most important for the nurse to collect?

The time of the client's last void A client who is pregnant and is undergoing abdominal ultrasound requires a full bladder for the test to be most accurate. The full bladder helps to lift the gravid uterus out of the pelvis during the examination. The nurse should determine if the client has a full bladder prior to the ultrasound. The time of the client's last void is the most important information for the nurse to collect.

A nurse is preparing to elicit the fencing reflex from a newborn. Which of the following actions should the nurse take?

Turn the newborn's head quickly to one side. The nurse will turn the newborn's head quickly to one side when eliciting the fencing reflex. The newborn will then extend the extremities in the direction he is facing with the opposite extremities flexing.

A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?

Use a 20-gague needle, and administer the medication using the Z-track method. The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.

A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the nurse include in the teaching as a nutrient for the client to increase the intake of while breastfeeding?

Vitamin C Vitamin C is important for tissue formation and integrity. The nurse should instruct the client to consume 115 to 120 mg of vitamin C per day, which is an increase from when the client was pregnant.