Maternal Newborn final

A nurse is reinforcing education about the prevention of newborn abduction with a client who recently delivered. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"An alarm will sound if someone removes my baby's safety device."

A nurse is reinforcing teaching about newborn home safety precautions with a group of new mothers. Which of the following instructions should the nurse include?

"Crib slats should be no more than 2.25 inches apart."

A nurse is reinforcing discharge teaching about home care with the parent of a newborn. Which of the following instructions should the nurse include?

"Ensure the water temperature during your newborn's bath is maintained at 100 F."

A nurse is reinforcing teaching with a client who has a new prescription of medroxyprogesterone acetate injection for contraception. Which of the following statements by the client indicates understanding of the teaching?

"I am likely to gain weight while taking this medication."

A nurse is reinforcing teaching with a client who is at 8 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching?

"I should expect to have a white vaginal discharge during pregnancy."

A nurse is reinforcing teaching about brestfeeding with a client who has a 12-hr-old newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I should wake up my baby to feed during the night."

A nurse is reinforcing teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will position the retainer clip at the level of the baby's armpits."

A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will report any drainage from my baby's umbilical cord."

A nurse is reinforcing teaching with a client who has an intrauterine device (IUD). Which of the following statements by the client indicates an understanding of the teaching?

"If I have pain during intercourse, I will notify my doctor."

A nurse is reinforcing teaching with a client who is at 16 weeks of gestation, has diabetes mellitus, and has a BMI of 31. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"My intake should be 25 calories per kilogram of my body weight or less per day."

A nurse is caring for a client who is postpartum and is receiving carboprost. Which of the following statements should the nurse identify as an indication that the client understand the purpose of this medication?

"This medication will slow down my bleeding."

A nurse is reinforcing teaching about preventing urinary tract infections with a client who is at 25 weeks of gestation. Which of the following instructions should the nurse include?

"You should empty your bladder before you go to bed at night."

A nurse is reinforcing teaching with a client who has a bacterial infection. Which of the following statements should the nurse include int he teaching?

"You should suspend breastfeeding for 8-10 days."

A nurse is reinforcing teaching about a nonstress test with a client who is at 33 weeks of gestation. Which of the following statements should the nurse include?

"You will press a button when you feel the baby move."

A nurse is caring for a client who is 18 hr postpartum and has a fourth-degree perineal laceration. The client reports a pain rating of 4 on a scale from 0-10. Which of the following should the nurse take? (SATA)

-Promote the use of witch hazel pads -Give the client ice packs -Have the client take a cool water sitz bath -Encourage the client to practice relation techniques

A nurse is caring for a client who is 48 hr postpartum following a vaginal delivery. Which of the following findings should the nurse report to the provider? (SATA)

-Reddened area on the calf -Dysuria -Cracked nipples

A nurse is reinforcing teaching with a client who is trying to become pregnant. Which of the following foods should the nurse recommend as the best source of folate?

1 cup cooked spinach

A nurse is reinforcing teaching about Ford sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate?

1/2 cup dried peas

A nurse is assisting with the care of a client who is postpartum and is receiving lactated Ringer's 1,500 mL IV to infuse over 10 hr. The nurse should verify that the IV pump's settings will deliver how many mL/hr?

150 mL/hr

A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider?

2+ urinary protein

A nurse is preparing to administer clindamycin 450 mg PO to a client who has endometritis. The amount available is clindamycin 150 mg/capsule. How many capsules should the nurse administer?

3 capsules

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?

A client who is at 37 weeks of gestation and reports a persistent headache

A nurse is collecting data from a client who is receiving magnesium sulfate. Which of the following feedings should the nurse report to the provider?

Absent deep-tendon reflexes

A nurse is contributing to the plan of care for a client who has eclampsia. Which of the following interventions should the nurse identify and plan to include as the priority immediately following a seizure?

Administer oxygen via facemask at 10L/min.

A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include?

Allow 20-30 minutes for feedings.

A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider?

Apical heart rate of 90/min while crying

A nurse is contributing to the plan of care for a newborn who was circumcised with a plastic bell device. Which of the following actions should the nurse include in the pain?

Apply pressure with sterile gauze if bleeding occurs at the site.

A nurse is reinforcing teaching with a client who is pregnant and will undergo a 1-hr oral glucose tolerance test. Which of the following instructions should the nurse include?

Avoid caffeine the morning of the test.

A nurse is caring for a client who is 2 hr postpartum. The nurse locates the client's fundus 2 cm above the umbilicus, with displacement to the right of the midline, and notes it is boggy. The nurse should identify which of the following complications as the likely cause of these findings?

Bladder distention

A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

Blood glucose 28 mg/dL

A nurse is collecting data from a client who is at 37 weeks of gestation. Which of the following findings should the nurse report to the provider?

Blurred vision

A nurse is collecting data from a client who is at 36 weeks of gestation during prenatal examination. Which of the following findings should the nurse report to the provider?

Blurred vision (Preeclampsia)

A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching?

Breastfeed the newborn at least every 2 hr.

A nurse is assisting with the care of a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. The client has a respiratory rate of 10/min. Which of the following medications should the nurse expect a charge nurse to administer to the client?

Calcium glutinate.

A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication?

Cessation of uterine contractions.

A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first?

Check the newborn's blood glucose level.

A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include?

Consume small meals frequently each day.

A nurse is collecting data from the parent of a newborn immediately following birth. The parent states, "She is so tiny. We don't know how to pick her up without hurting her." Which of the following actions should the nurse take first to promote parent-newborn attachment?

Demonstrate to the parent how to hold the newborn.

A nurse is monitoring a client who is in the first stage of labor and received IV fentanyl citrate 10 min ago for pain. The client has slurred speech and an altered mental status. Which of the following actions should the nurse take first?

Determine the client's oxygen saturation level.

A nurse is collecting data from a client who is primigravida and has hyperthyroidism. Which of the following findings should the nurse expect?

Diaphoresis

A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 hr following delivery?

Diuresis Discharge of clear, yellow fluid from the breasts Lower abdominal cramping

A nurse is contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend in the plan?

Drink 2 L of water per day.

A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy?

Epigastric Pain

A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take?

Explain to the client that she will receive the hepatitis B immune globulin immediately

A nurse is contributing to the plan of care for a client who is postpartum and follows kosher dietary laws. Which of the following indicates a meal the nurse should offer this client?

Foods that avoid eating meat and dairy products together.

A nurse is collecting data from a 28-year-old client who is requesting a prescription for an oral contraceptive. Which of the following information in the client's history should the nurse identify as a contraindication for the use of oral contraceptives?

Frequent headaches with visual changes.

A nurse is collecting data from a client who is in her second trimester of pregnancy. Which of the following findings should the nurse report to the provider?

Frequent uterine contractions

A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine prenatal visit. Which of the following findings in the data from the client's medical record should the nurse report to the provider?

Fundal height The height of the fungus in centimeters at 20 weeks of gestation is approximately the same as the number of weeks of gestation plus or minus 2 cm.

A nurse is collecting data from a client who gave birth 18 hr ago. Which of the following findings should the nurse identify as an indication of a postpartum complication?

Fundus is palpable at 2cm above the umbillicus.

A nurse is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provide?

Glycosuria

A nurse is assisting with the care of a client who is in the active phase of the first stage of labor. Which of the following findings should the nurse report to the charge nurse?

Green fluid from the vagina.

A nurse is caring for a client following a cesarean birth. Which of the following actions should the nurse take to decrease the client's risk of developing thrombophlebitis?

Have the client ambulate several times each day.

A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort?

Have the client perform relaxing breathing techniques.

A nurse in a postpartum unit is caring for a client who has endometritis and is 48 hr postpartum following a cesarean birth. Which of the following findings should the nurse anticipate?

Heart rate 110/min

A nurse is caring for a client 6 hours after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority?

Help the client ambulate to the toilet.

A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?

Hematocrit 30%

A nurse in an antepartum clinic is reviewing laboratory test results for multiple clients. The nurse should notify the provider of which of the following results?

Hematocrit 31%

A nurse is caring for a client who gave birth to a newborn who is large for gestation age (LGA) 16 hr ago. Which of the following findings should the nurse identify as a complication of the birth of a newborn who is LGA?

Hemorrhage

A nurse is caring for a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication?

Hypertension

A nurse is discussing family planning with a client who is requesting information about available contraceptive methods. Which of the following client statements indicates an understanding of the teaching?

I should use water-soluble lubricant when my partner wears a condom.

A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I will apply cold cabbage leaves to my breast throughout the day.

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

I will ask the nurse to take care of my baby in the nursery if I need to take a nap.

A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension with a client who is at 16 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching?

I will lie on my left side with my head elevated on a pillow. Avoid lying supine during pregnancy.

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

If my baby rides in a car with no back seat, the passenger air bag must be turned off.

A nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

Increase your fluid intake with this medication.

A nurse is caring for a client who is in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take?

Inject the medication into the client's vastus lateralis muscles.

A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take?

Insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria.

A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include?

Instruct the client to apply warm compresses to the affected breast

A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes?

Intramuscular

A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse identify as an indication that the client has hyperemesis gravid arum?

Ketonuria The nurse should identify that ketonuria is an indication of hyperemesis gravid arum. Ketonuria occurs due to the breakdown of fat secondary to malnutrition or starvation.

A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughter's room. Which of the following responses should the nurse make?

Let me wash my hands and then I'll take your grandson to his mother.

A nurse is reviewing the medication administration record for a client who is receiving nifedipine for gestational hypertension. The nurse should identify that which of the following medications is contraindicated for use with nifedipine?

Magnesium Sulfate

A nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend?

Monitor intake and output

A nurse is caring for a client who is receiving oxytocin. Which of the following manifestations should the nurse report to the provider?

More than 5 contractions in 10 min.

A nurse is reinforcing teaching about formula preparation with the mother of a newborn. Which of the following information should the nurse include?

Overdiluted formula can result in inadequate growth.

A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following findings should the nurse report to the provider?

Perineal pad soaked in 15 min

A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions should the nurse take?

Place an opaque mask over the newborn''s eyes.

A nurse is reviewing the laboratory results of a 4 hour old newborn. Which of the following findings should the nurse report to the provider?

Platelet count of 120,000 mm3

A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following?

Prevent certain kinds of birth defects

A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse?

Prolonged deceleration of FHR

A nurse on a postpartum uit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first?

Provide fundal massage for the client.

A nurse is planning to reinforce discharge teaching about formula feeding with the guardian of a newborn. Which of the following instructions should the nurse plan to include?

Provide the newborn with six to eight feedings during a 24-hr period.

A nurse is reinforcing discharge teaching with a client who has mastitis of the left breast. Which of the following instructions should the nurse include?

Pump the affected breast frequently

A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome?

Reactive non stress test

A nurse is collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider?

Respiratory rate 10/min

A nurse is reviewing the medical record of a client who is at 26 weeks of gestation. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?

Rheumatoid arthritis

A nurse is caring for a 12-hr-old male newborn who was delivered from a breech position. Which of the following findings should the nurse report to the charge nurse?

Skin appears jaundiced.

A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use?

Subcutaneous

A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider.

Tachypnea Nasal flaring Retrations Expiratory grunting

A nurse is observing a client bathe her 1 day old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe her newborn?

The client washes the newborn's hair before unwrapping her.

A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements indicates an understanding of the teaching?

Theis medication miight make me dizzy.

A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect?

Urine output of 3,000 mL in 24 hr

A nurse is planning to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Us the vests laterals as the injection site.

A nurse on a postpartum unit is contributing to the discharge teaching plan for a client. Which of the following instructions should the nurse suggest for the plan?

Use a firm mattress in the newborn's crib.

A nurse in a clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Use an ultrasound stethoscope to listen to fetal heart tones.

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings should the nurse identify as an indication of infection?

WBC 35,000 /mm3

A nurse is performing a blood collection via heel stick on a newborn for blood glucose monitoring. After washing her hands and donning gloves, which of the following actions should the nurse take next?

Warm the newborn's heel.

A nurse is assisting with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following images indicates a characteristic response of the tonic neck reflex?

When the newborn's head is quickly trurned to one side, the arm and leg on the same side extend, while the arm and leg on the opposite side flex.

A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include?

You will need to be in active labor before using hydrotherapy.

A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching?

Your fluid intake will be limited to no mare than 125 mL per hour to prevent fluid overload