Maternal Newborn Practice B 2019
A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?
"You can share your rm w/your baby for the next few wks." Rationale: The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.
Admin of azithromycin, 16 wks gestation, positive chlamydia culture Admin 1g orally NOW Avail: 250mg tablets How many tablets should the nurse admin?
1g into 1000 mg 1000mg/250mg= 4 tablets
lab report for 24hr old, result to report:
Blood glucose 30mg/dL Rational: reference range 50-90mg/dL
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
Cover the newborns eyes while under the phototherapy light Rational: Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.
Oxytocin, indication for administration:
Flaccid uterus, excess vaginal bleeding Rationale: Oxytocin increases the contractility of the uterus. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.
32 wks gestation, condition that indicate need for fetal assessment w/electronic fetal monitoring:
Oligohydramnios Rational: oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.
12hr old new born assessment, manifestation that requires intervention:
Substernal chest retractions while sleeping Rational: Can indicate respiratory distress syndrome in newborn
Spina bifida occulta:
Spot by tailbone
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?
" I will have blood test b/c my potassium might dec." Rational: An adverse effect of terbutaline is hypokalemia.
A nurse is teaching a client who is Rh negative about RH Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? Rh negative, statement indicating understanding:
" I will need this medication if I have amniocentesis." Rational: Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.
A nurse is teaching a client who is at 24 weeks of. gestation r egarding. a 1-hr glucose tolerance test. Which of the following. statements should the nurse include in the teaching?
"A blood glucose of 130-140 is considered a positive screening result." Rationale: The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of. the teaching?
"I will continue taking my insulin if I experience n/v." Rationale: The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.
Dietary teaching for hyperemesis gravid arum. understanding of teaching:
"I will eat foods that taste good instead of balancing my meals."
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of a client's newborn. Which of the following statements should the nurse make?
"Staff members who take care of your baby will be wearing a photo identification badge." Rational: The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.
Tubal ligation, "What effects will this procedure have on my sex life?":
"The procedure should have no effect on your sexual performance/adequacy."
preterm labor 29 wks, betamethasone, indication for med administraiton:
"This medication stimulates fetal lung maturity." Rationale: The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
"You can miss your period for several other reasons. Describe your typical menstrual cycle." Rational: Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? Teaching about family planning, new prescription for diaphragm:
"You should leave the diaphragm in place for at least 6hrs after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.
Teaching about levonorgestrel contraception, info to include In teaching:
"You should take the med w/in 72hrs following unprotected sexual intercourse." Rational: Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.
36 wk gestation, nonstress test:
"You will be offered orange juice to drink during the test."
Active labor, no cervical change in last 4hrs:
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.: Rational: Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.
Antepartum unit, client thats priority:
A client who is at 34 wks gestation & reports epigastric pain Rational: When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.
34 wks gestation, nursing plan to include:
Administer terbutaline Rational: terbutaline to stop contractions b/c lab results indicate fetus lungs not mature enough for birth
Client 3 days postpartum, nonpharmacologic intervention for lactation suppression:
Apply cabbage leaves to the breast. Rationale: Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.
Vaginal Examination, umbilical cord protruding from vagina, action to take:
Apply internal upward pressure to the presenting part using 2 gloved fingers Rational: Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?
Apply sacral counterpressure. Rational: The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.
gave birth vaginally 12hrs ago, palpates uterus to the right above umbilicus, intervention to perform:
Assist the client to empty her bladder. Rational: The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? Lab results for a 4hr old, finding to report:
Bilirubin 9mg/dL Rational: A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.
41 wk gestation, positive contraction stress test, diagnostic test the prepare client for:
Biophysical Profile (BPP) Rational: to further assess fetal well-being, positive stress test indicates potential uteroplacental insufficiency
lab report of newborn 24 hr old, which results to report to provider?
Blood glucose 30 mg/dL Rationale: Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.
Assessment for newborn following circumcision, indication newborn is experiencing pain:
Chin quivering Rationale: Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives? (SATA)
Cholecystitis, hypertension, migraine headaches Rational: Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives.
idiopathic thrombocytopenia purpura (ITP):
Decreased platelet count Rationale: A client who has ITP has an autoimmune response that results in a decreased platelet count.
2hr postpartum, interventions during taking-hold phases of behavior adjustment:
Demonstrate to the client how to perform a newborn bath. Rationale: Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.
client unresponsive following placenta delivery, action to take:
Determine respiratory function Rational: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.
Assess adaptation to pregnancy, "happy one minute & crying the next":
Emotional lability Rational: recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
Explain to the client this is an expected occurrence. Rational: Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.
client receiving Magnesium Sulfate IV, action to take:
Have calcium gluconate readily available
35 wk gestation, potential pregnancy complication, manifestations to include:
Headache that is unrelieved by analgesia Rational: indicate preeclampsia and should be reported to the provider.
10 wk gestation, lab finding to report:
Hemoglobin 10g/dL Rational: reference range of greater than 11g/dL for pregnant client
The nurse is preparing the client for surgery. Which of the following actions should the nurse take?
Inform the client to be NO prior to surgery is correct. Insert an 18-gauge peripheral I prior to surgery is correct. Obtain a complete blood count is correct. Verify a consent form is signed by the client is correct.
35 wk placenta previa, action to take:
Initiate continuous external fetal monitoring. Rational: client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth.
Nutritional intake, 8 wk gestation, inc daily intake of:
Iron (Fe) Rationale: The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.
A nurse is planning care for a client who is to undergo a non stress test. Which of the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected. Rational: Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.
Assessment for manifestations of hypoglycemia, finding to expect:
Jitteriness Rational: Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.
1st trimester, placement of the doppler ultrasound stethoscope in what location for FHT:
Just above the symphysis pubis. Rationale: At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
Leakage of fluid from the vagina Rational: Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.
A nurse is assessing fetal heart tones for a. client who is pregnant. The. nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?
Left lower Quadrant Rationale: The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.
Hypovolemic shocks, action to take:
Massage the clients fundus. Rational: The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.
Epidural anesthesia for pain control. action to include:
Monitor the clients BP/5 min following the 1st dose of anesthetic solution. Rational: The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution
Leopold maneuver, sequence:
Palpate the fundus, determine location of fetal back, palpate fetal part presenting at the inlet, palpate the cephalic prominence to identify attitude of head.
A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?
Place the retainer clip at the level of newborn armpits Rational: The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.
postpartum, preeclampsia, lab result to report:
Platelets 50,000 mm3. Rationale: A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.
Nageles rule: November 27th
September 3rd
A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider? Combined oral contraceptive, potential a/e:
Shortness of breath Rational: The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.
Bulb syringe, newborn secretions, instructions:
Stop suctioning when the newborns cry sounds clear Rationale: The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.
30 wks gestation, routine visit, finding to report:
Swelling of the face Rational: Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.
client in labor, amniotomy, assessment thats priority:
Temperature Rational: The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing 2-3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Transition Rational: This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds. The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds.
Newborn assessment, client took SSRI during pregnancy, manifestation thats identified as withdrawal:
Vomiting Rational: Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Transvaginal ultrasound is indicated. Meperidine IM is contraindicated. Repeat quantitative B-hCG level is anticipated. Methotrexate IM is anticipated. Blood typing is anticipated. Rationale: Transvaginal ultrasound is indicated. The nurse should anticipate a prescription for a transvaginal ultrasound. A transvaginal ultrasound is useful in determining the location of the ectopic pregnancy. Meperidine IM is contraindicated. Clients who receive methotrexate for an ectopic pregnancy should not take analgesics stronger than acetaminophen, because these medications can mask the manifestations of tubal rupture. Repeat quantitative β-hCG level is anticipated. The quantitative β-hCG level should be repeated within 48 hr to see if the level has changed from last recording. If increased levels are identified with no intrauterine pregnancy on ultrasound, this is indicative of ectopic pregnancy. Methotrexate IM is anticipated. The nurse should anticipate a prescription for methotrexate IM administration to prevent further embryonic cell reproduction. Blood typing is anticipated. The nurse should also anticipate potential surgical intervention for the client; therefore, blood typing is indicated.
Discharge teaching for postpartum, manifestation to monitor & report:
Unilateral breast pain Rational:Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.
newborn transferred into nursery 30min after birth, action to take first:
Verify the newborns identification. Rationale: When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.