Maternal Newborn & Peds (Questions & Review)

Myopia

nearsightedness - can see near but not far

A ("Harlequin's sign, manifested as one side of the body turning a deep red color, occurs when blood vessels on one side of the body constrict while those on the other side of the body dilate. The observance of Harlequin's sign should be documented and reported.") (Cafe au lait spots are flat, patchy, light brown areas.)

During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which finding? a) Mongolian spot b) Harlequin's sign c) port wine stain d) cafe au lait spots

A, B, C, E (s/s indicate possible ectopic pregnancy)

The nurse is assessing a multigravid client at 12 weeks' gestation who has been admitted to the emergency department with sharp right-sided abdominal pain and vaginal spotting. Which information should the nurse obtain about the client's history? Select all that apply. a) history of sexually transmitted infections b) number of sexual partners c) last menstrual period d) cesarean section e) contraceptive use

A, E (3rd stage = placental delivery)

The nurse is caring for a client who is in the third stage of labor. Which behaviors by the client does the nurse assess as expected at this stage? Select all that apply. a) focused on the neonate's condition b) exhausted from continued pushing c) apprehension about the process d) feeling embarrassed about an urge to defecate e) reports discomfort from uterine cramping f) excited about the anticipated process

C (normal to increase during contractions)

A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which should be the nurse's next action? a) Administer prescribed antihypertensive medication. b) Increase the rate of IV oxytocin. c) Continue to monitor BP. d) Position the client on the side.

C (oxytocin has antidiuretic effect)

A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care? a) inserting an indwelling catheter b) restricting oral intake c) monitoring intake and output d) maintaining bed rest

A (think of socialization needs)

The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the special care nursery (SCN) for respiratory distress. The nurse should place the new client in a room with which client? a) a G4 P4 who is 2 days postpartum with infant, Spanish speaking only b) a G1 P1 who is 1 day postpartum with an infant in the SCN c) a G6 P6 who gave birth 4 hours ago by C/S for fetal distress, infant at bedside d) a G1 P1 who is a non-English speaking client with infant in SCN for fetal distress

Lochia Rubra

Postpartum drainage - Bright red, clots, 1-3 days after delivery

A (r/t severe vasoconstriction. S/s abruptio placentae = board-like abd)

A client at 36 weeks' gestation, begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for: a) abruptio placentae b) uterine atony c) placenta accreta d) transverse lie

C (indicates diarrhea)

After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom? a) ability to fall asleep easily after each feeding b) spitting up of a tablespoon of formula after feeding c) passage of a liquid stool with a watery ring d) production of one to two light brown stools daily

B, C, D, E

The nurse is caring for a client in labor who states that she is concerned about needing an episiotomy. Which intervention(s) will the nurse include in the client's plan of care? Select all that apply. a) encourage pushing as soon as the client is completely dilated b) have client avoid the lithotomy position while pushing c) place warm or hot compresses on the perineum d) encourage client to use side-lying position for pushing e) encourage a gradual expulsion of the fetus

D (think: aorta supplies lower body)

Assessment of a term neonate at 8 hours after birth reveals tachypnea, diminished femoral pulses, and poor lower body perfusion. The nurse notifies the health care provider (HCP) based on the interpretation that these symptoms are associated with which complication? a) atrioventricular septal defect b) transposition of the great arteries c) pulmonary atresia d) coarctation of the aorta

Ambivalence, Confirmation, Vulnerable (concerned about loss)

Psychiatric Stages of Pregnancy -Choices: Vulnerable, Ambivalence, Confirmation -List in choices in correct order starting at 1st trimester, going to 3rd trimester

B (blocks seizure activity by interfering w/ signal transmission at neuromuscular junction)

The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The nurse's most appropriate response to is to tell the client that the priority reason for giving her magnesium sulfate is to a) increase diuresis. b) prevent seizures. c) slow the process of labor. d) reduce blood pressure.

A (so prescribed when a decrease in fetal heart rate/variability is noted)

The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose? a) increase in the fetal heart rate and variability b) assessment of the fetal hematocrit level c) increase in the strength of the contractions d) assessment of fetal position

A

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother? a) Continue feeding every 3 to 4 hours since the weight loss is normal. b) Contact the health care provider (HCP). c) Switch to a soy-based formula because the current one seems inadequate. d) Change to a higher-calorie formula to prevent further weight loss.

Chelation Therapy (RF seizures)

a procedure in which excess metals, such as iron, are removed from the blood

Hyperopia

farsightedness - can see far but not near

D

A client of Asian descent has been laboring for 3 hours. The nurse notes that a laboring client's temperature is elevated and her mucous membranes are becoming dry. The client has been refusing sips of water and ice that have been offered to her. Which is the most appropriate nursing action at this time? a) Encourage client to drink the ice and water. b) Offer the client hot beverages. c) Increase the IV oxytocin to 125 mL/hr for hydration. d) Ask the client what fluids she prefers to drink.

B (b/c pf drug use... would cause abrupt withdrawal)

A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The health care provider prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the drugs available at the time of the birth, which should the nurse avoid using with this client in this situation? a) pudendal block b) naloxone c) 1% lidocaine d) local anesthetic

Lochia Serosa

Postpartum drainage - Pink/brown d/c occurring 3-10 d postpartum

Lochia Alba

Postpartum drainage - creamy white or colorless d/c lasting 14d-6w

Increase, Decrease

Precipitous Labor = labor under 3 hours in length. Does this decrease or increase risk of: -Maternal Hemorrhage -Infection

Listen apically (tachycardia = early s/s of toxicity)

What should you do before administering digoxin?

C

When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? a) Apply an ice pack to the perineum. b) Massage the uterus every 15 minutes. c) Notify the physician. d) Assure the client that such bleeding is normal.

12-18 months

When does the anterior fontanel close?

C (Normally, the FHR accelerates with movement, indicating that the fetus has an intact autonomic nervous system that is not affected by uterine hypoxia. A reactive (normal) nonstress test with two accelerations going up 15 beats per minute and lasting 15 seconds in 20 minutes is a sign of fetal well-being. A nonstress test may be performed anytime after 32 weeks' gestation. SO REACTIVE IS GOOD)

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? a) "I'm sorry, your provider will have to inform you of the results of the test." b) "The fetal heart rate dropped during the contractions, so we may need to induce you." c) "The fetal heart rate went up twice during the test, so your fetus is doing well." d) "It is too early to tell, we will need to repeat the test in 2 weeks."

D (slow, dark trickle = s/s of postpartum hemorrhage; plan to admin oxytocic drugs)

The nurse is caring for a client during the 1st hour after a vaginal birth of a term neonate under epidural anesthesia and intravenous fluids. While assessing the client, the nurse observes that the client has a heart rate of 65 bpm, temperature of 99.9°F (37.7°C), fundus firm at one finger breath above the midline, and a slow trickle of dark red vaginal bleeding on the perineal pad. The client's legs are still numb. What action should the nurse take? a) Notify the anesthesiologist who performed the lumbar epidural anesthesia. b) Discontinue the client's intravenous fluids if the client is drinking fluids. c) Continue to monitor the client's temperature on an hourly basis. d) Massage the fundus and contact the client's primary care provider immediately.

C

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition? a) increased intensity of contractions b) fetal head engagement c) prolapsed cord d) a need for an analgesic medication

C

A female neonate born vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which action should the nurse take the first time that the parents visit the neonate in the nursery? a) Explain the surgical interventions that will be performed. b) Stress that this defect is not life-threatening. c) Emphasize the neonate's normal characteristics. d) Reassure the parents about the success rate of the surgery.

C

A multigravid client at 38 weeks' gestation is scheduled to undergo a contraction stress test. What should the nurse include in the explanation as the purpose of this test? a) evaluation of fetal lung maturity b) determination of the fetal biophysical profile c) assessment of fetal ability to tolerate labor d) determination of fetal response during movements

A

A neonate born by cesarean at 42 weeks' gestation, weighing 4.1 kg (9 lb), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. What is the priority problem for this neonate? a) hypoglycemia b) hyperthermia c) decreased cardiac output d) ineffective airway clearance

Increases (body using up everything to try to conserve warmth)

Cold stress ____ metabolic demand = hypoglycemia, resp distress, jaundice

Good (have accelerations)

Is a reactive NST a good or bad thing? What does it mean?

72 hours

Rh+ mom & Rh- NB = mom gets Rhogam within _____ b/c her body will make antibodies!

Scolios

Lateral curvature of the spine most common in females between ages 8-15

Cystitis

Lower UTI (bladder) -Common after 1st sexual intercourse

-3, +7, +1 (Double check! Add 9 mo. Be careful with year if LMP towards beginning of year)

Naegele's Rule: month, day, year

Rest the stomach

Other than having a procedure, why might a patient be NPO status?

False (decreases maternal blood sugar)

T or F: Breastfeeding does not affect maternal blood sugar

C

A 15-year-old primigravid client at approximately 16 weeks' gestation tells the nurse that she has been experiencing an occasional sharp pain from the fundus to her pubic bone on the left side. The nurse determines that the client is most likely experiencing which complication? a) fetal movement b) preterm labor c) round ligament pain d) appendicitis

A, C, E (baby likely already has infection from earlier feeding, do not stop breastfeeding... can cause engorgement which will worsen s/s)

A client who is 16 days postpartum calls the nurse on a postpartum unit crying. The client describes her nipples as being cracked and bleeding. The client also says her left breast is sore to touch, and an area under the breast is firm, painful, and red. She is scheduled to go to a nurse-led postpartum breastfeeding support group later that evening. How should the nurse respond to the client's descriptions of her symptoms? Select all that apply. a) Advise her to seek the advice of a lactation consultant to prevent future breastfeeding issues. b) Advise her to stop breastfeeding due to transfer of infection to the infant. c) Advise her to continue to breastfeed. d) Advise her to pump her breasts and discard this milk. e) Advise her to see her physician as soon as possible.

B

A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth? a) fluctuating body temperature b) respiratory distress c) peripheral and circumoral cyanosis d) fluctuating blood glucose results

B (showing s/s of septic shock)

A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100° F (37.8° C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should: a) Monitor the vital signs every 4 hours. b) Contact the primary care provider. c) Administer an analgesic as prescribed. d) Provide the client with clear liquids.

A

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? a) Administer pain medication per prescription. b) Replace ice packs to the perineum. c) Initiate anesthetic sprays to the perineum. d) Begin sitz baths.

A

The nurse is caring for a client in active labor and notes minimal variability on the external fetal monitor tracing. What are the nurse's priority interventions? a) Position to left lateral, O2 per nonrebreather mask at 10 L. b) Administer terbutaline, turn off oxytocin infusion. c) Give orange juice, vibroacoustic stimulation. d) Position to knee-chest, increase IV fluids.

Flexion Deformities

What is a big complication of juvenile arthritis? (Work to pv!)

A

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? a) "No, it can initiate premature uterine contractions." b) "Yes, it produces no adverse effects." c) "No, it can promote sodium retention." d) "No, it can lead to increased absorption of fat-soluble vitamins."

9 mo

When should an infant crawl?

B

A pregnant client with diabetes mellitus is at risk for having a large-for-gestational-age neonate because: a) excess insulin reduces placental functioning. b) insulin acts as a growth hormone on the fetus. c) excess sugar causes reduced placental functioning. d) the mother follows a high-calorie diet.

4-6 mo

When should infants roll over?

B (precipitous = fast birth)

During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which complication? a) urinary tract infection b) uterine atony c) postpartum "blues" d) intrauterine infection

C (observe for crowning)

The multigravid client with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" What should be the nurse's first action? a) Auscultate the fetal heart rate. b) Contact the health care provider. c) Inspect the perineum. d) Time the contractions.

B

The nurse hears a pregnant client yell, "Oh my! The baby is coming!" After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is being born. What should the nurse do first? a) Suction the mouth with two fingertips. b) Check for presence of a cord around the neck. c) Tell the client to bear down with force. d) Advise the mother that help is on the way.

1 mL/kg/hr

UOP for kids range

Increased ICP

What do the following indicate in an infant? -Bulging fontanels -Sun-setting eyes -Lethargy

D (also place on bed rest. B would induce b/c of oxytocin)

A nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor? a) serving a nutritious diet b) performing nipple stimulation c) encouraging ambulation d) promoting adequate hydration

D

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? a) prolonged decelerations b) late decelerations c) accelerations d) early decelerations

D

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions? a) with two fingertips b) with the fingers of one hand c) with the palm of one hand d) with the heel of one hand

B

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which sexually transmitted infection? a) syphilis b) herpes genitalis c) Chlamydia trachomatis infection d) gonorrhea

C (Meningocele = saclike protrusion filled with CSF and meninges, Myleomeningocele = saclike protrusion filled with CSF, meninges, nerve root and SC)

While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding? a) myelomeningocele b) meningocele c) spina bifida occulta d) spina bifida cystica

C (Ibuprofen and naproxen can lead to premature closure of ductus arteriosus and decrease amniotic fluid)

A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks? a) ibuprofen b) aspirin c) acetaminophen d) naproxen

D

A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? a) fundus b) back c) abdomen d) perineum

A (@ RF abruption r/t car accident)

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse's the priority action? a) Notify the provider of the pain and request an assessment for potential abruption. b) Perform a vaginal examination and coach the woman with breathing exercises for pain control. c) Assess the intensity of contractions and determine if she would like an epidural. d) Reassure the patient and assist with nonpharmacologic pain interventions.

B (Jaundice that persists after 3-4th day of life + pale, light stools = biliary atresia. Need surgical removal)

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider because these findings indicate which problem? a) esophageal varices b) biliary atresia c) Rh isoimmunization d) ABO incompatibility

C (S/S indicate tracheoesophageal fistual/TEF. Dx when gastric tube can't pass through stomach)

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and skin color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription? a) a lactation consultation b) an arterial blood gas c) an x-ray for gastric tube placement d) a serum blood glucose level

B

A nurse is admitting a child to the unit. Based on the history, what illness would the nurse suspect?History and physical10/151030Nine-year-old child admitted with frequent cough and fever of > 100.5° F (38.1° C) for the past month. Child lives with parents and with grandparents who recently emigrated from SE Asia. Weight = 20 kg. Parent reports significant weight loss in child. Child reporting fatigue and poor appetite. Denies vomiting/diarrhea. Does have some nausea. No problems with voiding or stooling. Child does well in school. a) pneumonia b) tuberculosis c) asthma d) HIV

A (C is false... doesn't occur)

A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? a) checking for the umbilical cord around the neonate's neck b) placing antibiotic ointment in the neonate's eyes c) turning the neonate's head to the side to drain secretions d) assessing the neonate for respirations

D (keeps pressure off presenting part of umbilical cord) (If a loop of cord discovered with vaginal exam --> keep gloved fingers in the vagina and push on fetal presenting part to relieve cord compression)

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? a) Palpate the cord for pulsations before notifying the physician. b) Attempt an external cephalic rotation. c) Restore circulation by stimulating the cord with a sterile glove. d) Place the mother in a knee-to-chest position.

D

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? a) acme of one contraction to the beginning of the next contraction b) beginning of one contraction to the end of the next contraction c) end of one contraction to the end of the next contraction d) beginning of one contraction to the beginning of the next contraction

D

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? a) "Wait until you have breastfed for at least 4 months." b) "Eliminate the baby's favorite feeding times first." c) "Plan to omit the daytime feedings last." d) "Gradually eliminate one feeding at a time."

C (uterine infection. Ab needed)

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for which problem? a) retained placental fragments b) uterine atony c) puerperal infection d) normal uterine involution

A

During labor, a low-risk multigravid client in active labor has begun pushing, and the fetal head is beginning to crown. What action should the nurse take to prevent perineal lacerations during the birth? a) Stretch the perineal tissues with sterile gloved fingers. b) Hold the fetal head back with a sterile gloved hand. c) Tell her to stop pushing during the next two contractions. d) Ask her to hold her breath while pushing during the entire contraction.

A (C - potter's synd = fatal condition involving facial deformities and renal agenesis) (D - turner's dyn = have 45 chromosomes = intellectual disabilities, long spine, delayed or absent sexual maturity)

While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? a) ambiguous genitalia b) renal disorders c) Potter's syndrome d) Turner's syndrome