Maternal Newborn 2, Maternal Newborn 1

A nurse is assessing a client who is at 35wks and has mild gestational HTN. which of the following findings should the nurse identify as the priority?

- 480ml urine output in 24hrs (this is not enough urine output, less then 30ml/hr. indicating progression of HTN, which requires immediate intervention.) 144/92 BP is an expected finding +2 edema is an expected finding for a client who is 35wk and had gestational HTN. +1 protein is an expected finding for a client who has gestational HTN.

A nurse is assessing a client who is 34wks and has a mild placental abruption. Which of the following findings should the nurse expect?

- Dark red vaginal bleeding. a normal platelet count would be expected for a client who has a mild placental abruption. a client with a mild placental abruption would have a reassuring fetal heart rate wnl urinary output should be WNL

A nurse is assessing a client who is 35wk and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following should the nurse report to the provider?

- Urinary output 20ml/hr deep tendon reflexes 2+ you would expect, but mag. can cause loss of deep tendon reflexes and should be reported. High blood pressure should be expected with PreE, BUT a BP greater then 160/110 should be reported. A RR less than 12 can indicate a mag toxicity and should reported.

a nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following lab tests will be used to confirm her pregnancy?

- a urine test for the presence of human chorionic gonadotropin HCG

A nurse is caring for a client who is at 32wks and is experiencing preterm labor. which of the following medications should the nurse plan to administer?

- betamethasone IM, a glucocorticoid to stimulate fetal lung maturity preventing respiratory depression. misoprostol- stimulates uterine contractions for a client undering IOL (induction of labor) methylergonovine - stimulated uterine contractions for a client who is experiencing PP hemorrhage. Poractant alfa - synthetic lung surfactant for a preterm newborn experiencing respiratory distress.

a nurse is providing teaching to a client who is 8wks about manifestations to report to the provider during pregnancy. which of the following info should the nurse include in the teaching?

- blurred or double vision (sign of preE, or HTN)

a nurse is caring for a client who is 35wks and has SEVERE preE. which of the following assessments provides the most accurate info regarding the clients fluid & electrolyte status?

- daily weight BP evaluates clients circulatory status intake and output evaluates clients fluid status severity of edema evaluates clients fluid status

a nurse is assessing a client who is at 12wks and has hydatidiform mole.(molar pregnancy) which of the following findings should the nurse expect?

- dark brown vaginal discharge

A nurse is reviewing the medical record of a client who is 39wk and has polyhydramnios. Which of the following findings should the nurse expect?

- fetal GI anomaly Fundal height would be greater then expected, pregnancy weight gain would be greater then expected, and gestational HTN causes oligohydramnios.

A nurse is teaching a client who is 13wks about the treatment of incompetent cervix with cervical cerclage. which of the following statements by the client indicates an understanding of the teaching?

- i should go to the hospital if i think i may be in labor

a nurse is caring for a client who believes she may be pregnant. which of the following findings should the nurse identify as a positive sign of pregnancy.

- palpable fetal movement. quickening is a presumptive sign chadwicks is a probable sign positive preg test is a probable sign ammenorrhea is a presumptive sign.

a nurse is reviewing the medical record of a client who is at 33wks and has placenta previa and bleeding. which of the following prescriptions should the nurse clarify with the provider?

- perform a vaginal examination should be clarified with the provider because you should NEVER preform a vaginal exam with placenta previa.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. the nurse notes a reassuring FHR tracing from the EXTERNAL fetal monitor. which of the following actions should the nurse take?

- prepare equipment needed for newborn resuscitation endotracheal suctioning is only recommended if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is caring for a client who has oligohydramnios(amniotic fluid volume less than 300ml during third trimester). Which of the following fetal anomalies should the nurse expect?

- renal agenesis (occurs when there is a renal system dysfunction or obstructive uropathy. absence of fetal kidneys can cause oligohydramnios.) fetal cardiac anomalies do not affect AFV Fetal NTD do not affect AFV fetal hydrocephalus does not affect AFV

a nurse is teaching a client who is at 12wks about manifestations of potential complications that she should report to her provider. which of the following info should the nurse include in the teaching?

- swelling of the face

A nurse is caring for a client who is 26wks and reports constipation. which of the following responses by the nurse is appropriate?

- you should walk for at least 30 mins every day. encourage moderate physical activity such as walking or swimming every day, this increases intestinal peristalsis. mineral oil during pregnancy can lead to severe cramping, diarrhea, fluid loss, and preterm contractions. red meat is high in IRON and contributes to constipation. you should not instruct client to stop taking prenatal vitamins.

a nurse is teaching a client who is 10wk about abdominal U/S in the 1st trimester. which of the following info should the nurse include in the teaching?

- you will need a full bladder.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?

-Apply pressure to the clients sacral area during contractions. (with palm or firm object like a tennis ball during contractions. counter pressure lifts fetal head away from sacral nerves which decreases pain) soaking in a warm bath (hydrotherapy) should be done in the ACTIVE phase of labor or 5cm dilated. Supine position should be avoided during labor because this can increase back pain. instructing client to pant during contractions PREVENTS pushing or bearing down before cervix is completely dilated during the transition phase of labor.

A nurse is caring for a 38wk pt and reports no fetal movement for 24hr. Which of the following actions should the nurse take?

-Auscultate for a fetal heart rate. Orange juice is good to stimulate a sleeping fetus. lack of fetal movement for 24 hr is NOT an expected finding. palpating the uterus for fetal movement is not a reliable method to assure fetal well being.

A nurse is reviewing lab results for a client who is 37wks. the nurse notes that the client is rubella non-immune, positive for group A beta- hemolytic streptococci, and has a blood type O negative. Which of the following actions should the nurse take?

-Instruct the client to obtain a rubella immunization AFTER delivery. administration of Rh (D) immune globulin should be given at 28wks and again within 72hr of delivery if newborn is Rh positive. the client will receive IV antibiotic during labor to prevent transmission of GROUP B STREP to the newborn. no lab findings indicate that the client needs a C/S

A nurse is teaching a client who is 8wks and has a uterine fibroid about potential effects of the fibroid during preg. which of the following info should nurse include in teaching?

-The fibroid can increase the risk for PP hemorrhage. uterine fibroids are more likley to GROW during pregnancy in response to increase estrogen. Client will undergo multiple U/S during pregnancy to monitor the fibroid. provider will NOT surgically remove d/t risk for fetal injury, death, or maternal hemorrhage. The size and location of fibroid will determine safest method for delivery. If fibroid is small and not near cervical os, she can have a VAG birth.

A nurse is teaching a 12wk client who has HIV. which of the following statements should the nurse include in teaching.

-You should continue to take zidovudine throughout the pregnancy (taking antiviral medication every day decreases risk of transmission of HIV to newborn) you should NOT breastfeed if you have HIV she can continue sexual intercourse as long as condom is used. client and newborn will only require standard precautions after delivery.

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous infusion. The nurse notes that the client is having contractions Q2min which last 100-110 seconds (1min-2min) and that the FHR is reassuring. Which of the following actions should the nurse take?

-decrease the dose of oxytocin by half because the client is experiencing uterine tachystole. nurse should administer oxygen via nonrebreather mask if FHR is nonreasurring. administration of terbutaline 0.25mg SQ would be done if FHR is nonreassuring. You would not decrease maintenance IV fluid.

a nurse is admitting a client who is in labor and experiencing moderate bright red vag bleeding. which of the following actions should the nurse take?

-obtain blood samples for baseline lab values like hemoglobin and hematocrit levels.

A nurse is teaching a client who has PreE and is to receive MAG via continuous IV about EXPECTED adverse effects. Which of the following adverse effects should the nurse include in the teaching.

-the nurse should tell the client to expect the feeling of warmth all over her body while the mag is infusing. BP is expected to decrease the client will feel well sedated generalized pruitius can be a manifestation of an allergic reaction.

A nurse is caring for a client who is 37wks and is undergoing a NST. the FHR is 130/min without accelerations for the past 10min. Which of the following actions should the nurse take?

-use vibroacoustic stimulation on the clients abdomen for 3secs to elicit fetal activity because the fetus is most likely sleeping. fetal movement should cause accelerations in the FHR a NST can be considered NON REACTIVE after 40mins of continuous monitoring w/o accelerations in the FHR despite vibroacoustic stimulation. a internal fetal scalp electrode is used during labor to monitor FHR

A nurse is assessing a client who is 37wks and has a suspected pelvic fracture due to blunt abdominal trauma. which of the following findings should the nurse expect?

-uterine contractions an increase in HR would be expected d/t trauma or blood loss, seizures would NOT be expected to trauma, and an increased RR would be expected.

a nurse is caring for a client who is 39wks and is in the active phase of labor. The nurse observes late decelerations in the FHR. which of the following findings should the nurse identify as the cause of the late decelerations?

-uteroplacental insufficiency

A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. which of the following findings should the nurse include in her teaching?

-vaginal bleeding mild constipation, nasal congestion, and 10 fetal movements an hour are all normal.

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer?

0.25

A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh?

1.8

A nurse is caring for a client whose LMP began July 8th. Using nagele's rule, the nurse should identify the clients EDB as which of the following?

April 15th

A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. What following statements should the nurse make? a. blood pools in the vagina when you are lying a bed b. the amount of blood flow will increase during the first few days after giving birth c. you might have retained placental fragments in your uterus d. you might have a damaged blood vessel

a. blood pools in the vagina when you are lying a bed

A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion

a. continue routine monitoring

A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment

a. place the newborn directly on the client's chest

A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse expect? a. symmetric rib cage b. lanugo abundant on the back c. dry, wrinkled skin d. vernix over the entire body

a. symmetric rib cage

A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3-4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe

a. this will resolve within 3-6 wks without treatment

A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7

b. 9

A nurse is administering a rubella immunization to a client who is 2 days postpartum. What statement indicates to the nurse the client needs further instruction? a. I cannot receive rubella immunization during pregnancy b. I can conceive anytime i want after 10 days c. I can continue to breastfeed d. I wills till need to have my provider perform a rubella titer with my next pregnancy

b. I can conceive anytime i want after 10 days

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. What instructions should the nurse include in the teaching? a. use prepackaged commercial wipes to clean the circumcision site b. encourage nonnutritive sucking for pain relief c. remove the yellow exudate with each diaper change d. apply the diaper tightly over the circumcision area

b. encourage nonnutritive sucking for pain relief

A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclera c. resp rate 50 d. cbg 60

b. jaundice of the sclera

A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions? a. mag sulfate b. methylergonovine c. terbutaline d. nifedipine

b. methylergonovine

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. stand under hot shower with your breasts exposed b. place ice packs on your breasts c. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra

b. place ice packs on your breasts

A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings

b. place the naked newborn on the mothers bare chest and cover both with a blanket

A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the nurse take to promote development? a. discourage the use of pacifiers b. position the naked newborn on the parents bare chest c. provide frequent periods of visual and auditory stimulation d. rapidly advance oral feedings

b. position the naked newborn on the parents bare chest

A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? select all a. oxytocin infusion b. prolonged labor c. mag sulfate infusion d. small for gestational age newborn e. distended bladder

b. prolonged labor c. mag sulfate infusion e. distended bladder

A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm

c. I will place my baby on his back when it is time for him to sleep

A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect? a. heel creases covering the bottom of the feet b. good flexion c. abundant lanugo d. dry, parchment-like skin

c. abundant lanugo

A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside? a. naloxone b. protamine sulfate c. calcium gluconate d. atropine

c. calcium gluconate

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rate b. bp c. fundal consistency d. output

c. fundal consistency

A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milk b. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore

c. it is normal for my baby to sometimes feed every hr for several hours in a row

A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse expect? a. temp of one leg differing from that of the other b. symmetrical gluteal folds c. limited abduction of one hip d. legs that are shorter than the arms

c. limited abduction of one hip

A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification? a. initiate bedrest with HOB elevated b. initiate high-fiber diet for client c. monitor clients wt wkly d. monitor client's I&O

c. monitor clients wt wkly

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterus b. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area

c. slow trickle of bright vaginal bleeding and a firm fundus

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal region b. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings

c. use photometer to monitor the lamp's energy

A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway

d. assist the client to ambulate in the hallway

A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder

d. assist the client to empty her bladder

A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include? a. discard unused refrigerated formula after 72 hrs b. prop the bottle with a blanket for the last feeding of the day c. dilute ready-to-feed formula if the newborn is gaining wt too quickly d. boil water for powdered formula for 1-2 min

d. boil water for powdered formula for 1-2 min

A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1-2 hr of delivery? a. poractant alpha b. rotavirus immunization c. naloxone d. erythromycin ophthalmic ointment

d. erythromycin ophthalmic ointment

A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. moro b. babinski c. rooting d. tonic neck

d. tonic neck