Maternity Final Practice Questions

A new mother is on a chemotherapeutic agent, and is unable to breastfeed her newborn. She asks the nurse for guidance in feeding her neonate. What is the nurse's most appropriate response? a. "Infant formula is a healthy alternative if you are unable to breastfeed" b. "Neonates require less feedings because formula is harder to digest" c. "If you use infant formula, you don't have to worry about what you eat or drink" d. "Formula feeding requires planning and organization to make sure you have what you need"

a. "Infant formula is a healthy alternative if you are unable to breastfeed"

A neonate is born after 36 weeks gestation to a mother who used tobacco, alcohol and marijuana during pregnancy. Which findings indicate the impact of substance abuse on the neonate? (Select all that apply) a. Birth weight of 1,800g b. Delayed passage of meconium c. Facial abnormalities d. Increase in sleep state e. High-pitched cry

a. Birth weight of 1,800g c. Facial abnormalities

The nurse is performing an assessment on a neonate. Which assessment finding is suggestive if hypothermia? a. Bradycardia b. Hyperglycemia c. Metabolic alkalosis d. Shivering

a. Bradycardia

Which behavior should the nurse expect to observe in a client on the 4th postpartum day? a. The client asks many questions about the baby's care b. The client wants to relate her birth experience c. The client asks the nurse to select her meals for her d. The client asks the nurse to help bathe herself

a. The client asks many questions about the baby's care (taking hold phase lasts 3-10 days postpartum)

A full term infant has just been delivered without complications. Which assessment findings would indicate successful adaptation to extrauterine life? (Select all that apply) a. Nasal flaring b. Apar scores of 9 at 5 minutes c. Respiratory rate of 42 d. The infant nursed in delivery room e. Axillary temp 36.5 'C (97.7 'F) f. Sleeping quietly

b. Apar scores of 9 at 5 minutes c. Respiratory rate of 42 d. The infant nursed in delivery room e. Axillary temp 36.5 'C (97.7 'F)

Which intervention best addresses the needs of a term infant who has central cyanosis and adequate respiratory and heart rates? a. Provide tactile stimulation b. Give supplemental free-flow oxygen c. Assist ventilation with a bag and mask d. Intubate and suction lower airway

b. Give supplemental free-flow oxygen

The nurse is counseling the expectant teen mother about the benefits of breastfeeding. What are these benefits? (Select all that apply) a. Decreased risk of prematurity b. Increased chance of higher intelligence in the baby c. Decreased risk of mastitis d. Decrease risk of SIDS e. Decreased risk of childhood obesity f. Increased chance of return to pre-pregnant weight

b. Increased chance of higher intelligence in the baby d. Decrease risk of SIDS e. Decreased risk of childhood obesity

A nurse in the nursery is serving as a preceptor for a student nurse. The student asks the nurse why a neonate's head is cone shaped. Which response is accurate? a. It results from a fast delivery. The fast labor caused bruising and swelling of the neonate's head b. It results from molding. Overriding of the cranial sutures allows for the neonate's head to fit through the birth canal c. It results from a cephalhematoma. Some blood has collected between the skull bone and periosteum. d. It results from hydrocephalus. Either too much CSF is being formed or too little is being absorbed.

b. It results from molding. Overriding of the cranial sutures allows for the neonate's head to fit through the birth canal

A nurse is caring for a woman in active labor. The electronic fetal monitor reveals a FHR less than 70 bpm for 1 minute. What is the priority intervention? a. Position the mother in the lithotomy position b. Place the mother on her left side and apply oxygen c. Call the HCP d. Slow down IV rate

b. Place the mother on her left side and apply oxygen

The nurse is assessing a 6 week postpartum client in the OB's office. In the exam room the nurse asks the client how she is feeling. She bursts into tears and reports she cries most of the time, feels like a failure and can barely get out of bed to dress. The nurse suspects the client is experiencing: a. Postpartum blues b. Postpartum depression c. Postpartum neurosis d. Postpartum psychosis

b. Postpartum depression

Which finding would the nurse consider to be a normal physiologic response in the early postpartum period? a. Urinary urgency and dysuria b. Rapid diuresis c. Decrease in BP d. Increased motility of the GI tract

b. Rapid diuresis

A nurse is caring for a newborn with fetal alcohol syndrome. Which finding is most indicative of FAS? a. Delayed development b. Smooth philtrum c. Hearing loss d. Growth retardation

b. Smooth philtrum

The nurse is performing an assessment on a term neonate. Which finding is considered common in the healthy neonate? a. Single palmar crease b. Subconjuntival hemorrhages c. Lanugo over back d. Caniotabes

b. Subconjuntival hemorrhages

The nurse is assessing the FHR of a laboring woman who is full term. Which finding should the nurse recognize as normal value? a. 80-100 BPM b. 100-120 BPM c. 120-160 BPM d. 160-180 BPM

c. 120-160 BPM

A 3 day old infant has orders to begin phototherapy for hyperbilirubinemia. The nurse teaches the parents how to use overhead phototherapy lights. Which info should be included in the teaching? (Select all that apply) a. Diuretics are given during treatment since bilirubin is excreted in urine and stool b. Feed the neonate under phototherapy lights throughout the treatment to prevent dehydration c. A mask is placed over the eyes to prevent retinal damage d. The temperature is monitored frequently during phototherapy e. The neonate may develop loose green stools with phototherapy f. Place the bassinet near the window at home for sun exposure after discharge home

c. A mask is placed over the eyes to prevent retinal damage d. The temperature is monitored frequently during phototherapy e. The neonate may develop loose green stools with phototherapy

The nurse is reviewing the glucose tolerance test results of a client who is at 26 weeks gestation. The nurse determines further intervention is necessary when the results identify: a. A glucose lvl of 120 mg/dL during a 1 hour glucose tolerance test b. A one hour glucose lvl of 160 mg/dL during a 3 hour glucose tolerance test c. A two hour glucose lvl of 180 mg/dL during a 3 hour glucose tolerance test d. A three hour glucose lvl of 130 mg/dL during a 3 hour glucose tolerance test

c. A two hour glucose lvl of 180 mg/dL during a 3 hour glucose tolerance test (should be no higher than 155 mg/dL)

The nurse is caring for a client in active labor. Which components of labor contractions would be most accurate for the nurse to assess? a. Pelvic type, duration, contraction and frequency b. Contraction type and frequency and pelvic type c. Contraction duration, frequency, and intensity d. Contraction type, duration and intensity

c. Contraction duration, frequency, and intensity

A client hospitalized for preterm labor tells the nurse she is having occasional contractions. Which is the most important intervention? a. Explain the possible complications of preterm birth b. Tell the client to ambulate in the hall c. Encourage the client to empty her bladder, give IV fluids, and encourage oral fluids d. Notify anesthesia for immediate epidural placement to relieve pain associated with contractions

c. Encourage the client to empty her bladder, give IV fluids, and encourage oral fluids

The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurses priority assessment? (Select all that apply) a. Blood glucose lvl b. Electrocardiogram c. Height of fundus d. Blood pressure e. Urinary output

c. Height of fundus d. Blood pressure e. Urinary output (focused assessment every 15 minutes for first 1-2 hrs postpartum, including assessment of lochia, fundus, perineum, BP, pulse, and bladder function)

Which nursing intervention would help prevent evaporative heat loss in the neonate immediately after birth? a. Administering warm oxygen b. Controlling drafts in the room c. Immediately drying the infant d. Placing infant on a warm, dry towel

c. Immediately drying the infant

A multiparous client who has been in labor for 2 hrs states she has the urge to move her bowels. What should the nurse do first? a. Assist the client to get up to use the toilet b. Assist the client to use the bedpan c. Perform a pelvic examination d. Check fetal heart rate

c. Perform a pelvic examination (rectal pressure may indicate low presenting fetal part and imminent birth)

The nurse is assessing a client with type 1 diabetes. The client's birth was complicated by polyhydraminos and macrosomia. The nurse is aware this client is at risk for: a. Postpartum mastitis b. Increased insulin needs c. Postpartum hemorrhage d. Gestational hypertension

c. Postpartum hemorrhage (Uterus is overextended and may not be able to contract as well)

Which maternal complication is most commonly associated with obesity in pregnancy? a. Mastitis b. Placenta previa c. Preeclampsia d. Rh Isoimmunization

c. Preeclampsia

A home health nurse assesses a neonate who is 48 hrs old, and was discharged from the hospital 24 hrs ago. Which assessment finding indicates a potential problem? a. The neonate cries but no tears appear b. Small papules appear all over the newborn's skin c. The neonate doesn't turn his head in the direction his cheek is stroked d. The neonate produces a greenish-brownish stool

c. The neonate doesn't turn his head in the direction his cheek is stroked (May indicate neurological problem, which should be communicated to the HCP)

While performing an initial assessment on a term neonate, the nurse notices a bluish marking across the neonate's lower back, What information should the nurse share with the mother regarding this marking? a. This mark is commonly found in babies born by c-section b. This resulted from poor nutrition during pregnancy c. This marking is a "blue-birthmark" and is typically found in dark-skinned races d. This will happen when the infant is cold

c. This marking is a "blue-birthmark" and is typically found in dark-skinned races (Mongolian spot)

Which clinical finding does the nurse find most suggestive of physiologic jaundice in an infant? a. Clinical jaundice before 36 hrs of age in baby with family history of neonatal jaundice b. Clinical jaundice in breastfeeding neonate c. Total bilirubin lvls of 12 mg/dl by 3 days of life d. Serum total bilirubin lvls increasing by more than 5 mg/dl/day

c. Total bilirubin lvls of 12 mg/dl by 3 days of life

The nurse reviews the assessment findings of a postpartum client who has experienced a vaginal birth. Which finding should the nurse consider normal for this client? a. Redness or swelling in calves b. A palpable uterine fundus beyond 10 days postpartum c. Vaginal dryness after lochial flow has ended d. Dark red lochia for approximately 6 weeks after birth

c. Vaginal dryness after lochial flow has ended (due to hormonal changes)

A client with active genital herpes is admitted to the L&D area in the 1st stages of labor. Her contractions are 5-6 minutes apart and she is dilated 2-3 cm, 40% effaced at -2 station with intact membranes. What type of birth would the nurse anticipate? a. Mid forceps b. Low forceps c. Pitocin induction d. Cesarean

d. Cesarean

Which neonate would be least likely to develop respiratory distress syndrome? a. Second born of twins b. Neonate born at 34 weeks c. Neonate of a diabetic mother d. Chronic maternal hypertension

d. Chronic maternal hypertension (Fetal stress tends to increase lung maturity)

The cervix of a 26 yr old primigravida in labor is 5cm dilated and 75% effaced and the fetus is at zero station. The provider prescribes an epidural regional block. in which position should the nurse place this client to allow for an epidural regional block a. Lithotomy b. Supine c. Prone d. Lateral

d. Lateral

The nurse is aware that preterm neonates who receive prolonged mechanical ventilation at birth are most at risk for which condition? a. Chronic lung disease b. Alveolar rupture c. Bradycardia d. Air-trapping

a. Chronic lung disease

The nurse is planning care for a client receiving magnesium sulfate for hypertension. Which medication should the nurse have available for an emergency? a. Calcium gluconate b. Hydralazine c. Naloxone d. Rho(D) Immune Globulin

a. Calcium gluconate

Nurse is providing care for a neonate with in utero alcohol exposure. Prioritize infant care interventions. a. Dim the lights and decrease the sound b. Monitor neonate's blood glucose c. Educate the mother on the need to follow up appointments with therapy services d. Have the mother breast feed the neonate every 2-3 hrs e. Obtain a hearing screen

a. Dim the lights and decrease the sound b. Monitor neonate's blood glucose d. Have the mother breast feed the neonate every 2-3 hrs e. Obtain a hearing screen c. Educate the mother on the need to follow up appointments with therapy services

A client who is pregnant has developed preeclampsia. She asks the nurse why magnesium sulfate has been prescribed to her. What is the nurse's best response? a. "It prevents hemorrhage" b. "It prevents hypertension" c. "It prevents hypoglycemia" d. "It prevents seizures"

d. "It prevents seizures"

A nurse is performing an assessment on a neonate. Which assessment findings would indicate a metabolic response to cold stress? a. Arrythmias b. Hypoglycemia c. Respiratory Distress d. Jaundice e. Increase in blood pressure

b. Hypoglycemia c. Respiratory Distress d. Jaundice

A nurse is caring for a term newborn who has developed respiratory problems after being born through c-section due to failure to progress. Which condition is most likely causing this problem? a. Neonatal respiratory distress syndrome b. Meconium aspiration c. Pneumothorax d. Transient tachypnea of a newborn

d. Transient tachypnea of a newborn (Caused by a delay in removing excess lung fluid, often with C-Section babies)

A client is receiving IV magnesium sulfate for severe preeclampsia. Which is the priority assessment for this client? a. Anemia b. Decreased urine output c. Hyperreflexia d. Increased respiratory rate

b. Decreased urine output

The nurse is preparing a plan of care for a client who has had a cesarean birth. What should be included in the discharge plan? a. Douche frequently after being discharged b. Do coughing and deep breathing exercises c. Begin doing sit ups 2 weeks post-op d. Do side rolling exercises

b. Do coughing and deep breathing exercises

Which finding by the nurse would be most indicative for fetal distress during labor? a. Fetal scalp pH of 7.14 b. Fetal heart rate 144 bpm c. Acceleration of FHR with contractions d. Presence of long term variability

a. Fetal scalp pH of 7.14

The nurse is prepping a client in labor for administration of an epidural. What is the most important intervention by the nurse? a. Give a fluid bolus of 500ml b. Administer IV pain medications per provider's orders c. Elicit maternal reflexes d. Insert a Foley catheter

a. Give a fluid bolus of 500ml

A nurse is monitoring a client in labor and notes FHR slows with the start of each contraction on the fetal monitor. What action should be taken by the nurse? a. Turn client to left side b. Continue to observe FHR c. Administer oxygen by face mask d. Place the client in Trendelenburg position

b. Continue to observe FHR (Early decelerations are result of head compression and are not a sign of fetal distress)

A nurse is assessing a laboring client who is in the second stage of labor. What findings would the nurse expect to note? a. Cervical dilation of 8cm b. Crowning of the fetal head c. Contractions continuing to deliver the placenta d. Contractions every 3-5 minutes lasting 60 seconds

b. Crowning of the fetal head (2nd stage begins with full dilation and ends with baby being born)

During an assessment of a postpartum client the nurse notes a continuous blood flow from the vagina and a firm uterus 1cm below the umbilicus. Which complication does the nurse suspect this client may be experiencing? a. Retained placental fragments b. UTI c. Cervical laceration d. Uterine atony

c. Cervical laceration

An Rh positive mother has delivered a 6lb 10 oz baby vaginally, after 17 hours of labor. What factor would place this client at risk? a. Length of labor b. Maternal Rh status c. Method of birth d. Size of the baby

a. Length of labor (Prolonged labor increases risk of infection)

A nurse is performing an assessment of a client 2 hrs postpartum and notes heavy bleeding with large clots. What should be the nurses initial action? a. Massaging the fundus firmly b. Performing bi-manual uterine compressions c. Administering ergonovine d. Notify HCP

a. Massaging the fundus firmly

A client is diagnosed with postpartum preeclampsia and asks the nurse what could have caused this to occur. Which causative factors should the nurse include in her teaching? (Select all that apply) a. Obesity b. Prolonged labor c. Fetal distress at birth d. Poor diet e. Damage to blood vessels during birth

a. Obesity d. Poor diet e. Damage to blood vessels during birth (May occur up to 6 weeks after birth)

Which circumstance of delivery would place the neonate at the highest risk of respiratory distress syndrome? a. Preterm birth b. Infant of a diabetic mother c. Twin gestation d. Infant born through thick meconium

a. Preterm birth

While assessing a client in her 24th week of pregnancy, the nurse learns the client has been experiencing signs and symptoms of pregnancy-induced hypertension, or preeclampsia. What sign or symptoms helps differentiate preeclampsia from eclampsia? a. Seizures b. Headaches c. Blurred vision d. Weight gain

a. Seizures

Which client activity would indicate effective teaching about effective perineal care postpartum? a. The client uses a spray bottle to cleanse the perineum after urination and bowel movements b. The client wipes the perineum from back to front after urinating or bowel movement c. The client douches after urinating or bowel movement d. The client changes perineal pads 3 times a day

a. The client uses a spray bottle to cleanse the perineum after urination and bowel movements

Which fetal position would be considered most favorable for birth? a. Vertex presentation b. Transverse lie c. Frank breech d. Posterior position of fetal head

a. Vertex presentation

Which client behavior indicates an understanding of the nurse's teaching plan for breastfeeding? a. The client washes her nipples with soap and water b. The client lets her nipples air dry c. The client lets the baby attach to the nipple only d. The client pulls the baby off the nipple when feeding is done

b. The client lets her nipples air dry

A nurse is treating a postpartum client a few days after birth. Which verbalization should be cause for concern? a. The client states she is nervous about taking her baby home b. The client tells the nurse she feels empty since she has delivered the baby c. The client asks if she can watch the nurse give the baby the first bath d. The client says she would like the nurse to take her baby to the nursery so she can sleep

b. The client tells the nurse she feels empty since she has delivered the baby (May be an indication of postpartum blues, may also verbalize she feels unprotected now)

The nurse is caring for 4 clients on an antepartum unit. What is the earliest gestational age that a conceptus is considered viable? a. 9 weeks b. 14 weeks c. 24 weeks d. 30 weeks

c. 24 weeks

A breastfeeding mother who is experiencing engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? a. Applying ice b. Applying a breast binder c. Teaching how to express the breasts d. Administering bromocriptine

c. Teaching how to express the breasts (Facilitates let-down and provides temporary relief)

A 29 yr old client has gestational diabetes. The nurse is teaching her about managing glucose lvls. Which therapy would be most appropriate for this client a. Diet b. Long-Acting Insulin c. Oral hypoglycemic drugs d. Glucagon

a. Diet

A nurse assisting in monitoring a client in laboring. Which monitoring data are indicative of fetal well being? a. FHR of 145-155 bpm with 15 second accelerations to 160 bpm b. FHR of 130-140 bpm with late deceleration to 110 bpm c. FHR of 110-120 bpm with variable deceleration to 90 bpm d. FHR 165-175 bpm with late decelerations to 140 bpm

a. FHR of 145-155 bpm with 15 second accelerations to 160 bpm

4 clients each gave birth 12 hours ago. Based upon report and assessment, which client should the nurse see first? a. Gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin 9.8g/dl b. Gravida 2 Para 1011, cesarean birth, incisional site intact, pulse 84 bpm c. Gravida 1 Para 1001, vaginal birth, midline episiotomy, temperature 99.8 (37.7 'C) d. Gravida 1 Para 1001, vaginal birth, ruptured membranes 10 hours before birth

a. Gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin 9.8g/dl (Anemia <10 g/dl, risk for impaired wound healing and inability to tolerate activity)

Which assessment of a patient 22hrs after cesarean birth would require immediate intervention by the nurse? a. HR of 132 bpm, and BP of 84/60 mmHg b. Oral temperature of 100.2 (37.9 'C) c. A gush of blood from the vagina when the patient stands up d. Reports of abdominal pain and cramping

a. HR of 132 bpm, and BP of 84/60 mmHg (Tachycardia and Hypotension may indicate hemorrhage)

A client with mild preeclampsia is being prepared for discharge from the hospital. The client understands the discharge instructions when she states: a. "I will lie on my left side" b. "I should increase my sodium intake" c. "I will take acetaminophen for headaches" d. "I will monitor my weight every week"

a. "I will lie on my left side"

A client at 35 weeks gestation tells the nurse she is worried because she is having irregular abdominal contractions that have remained irregular for the past few days. How should the nurse best explain these contractions to the client? a. "These contractions will disappear when you walk" b. "These contractions will increase in frequency and intensity" c. "These contractions will become regular" d. "These contractions will move to the lower back"

a. "These contractions will disappear when you walk" (Braxton Hicks contractions)

The nurse connects a laboring woman to an external fetal monitor. The client asks the nurse the purpose of this machine. What should the nurse educate the client about the fetal monitor? a. "It monitors fetal kicks" b. "It assesses fetal position" c. " It determines how the labor is progressing" d. "It monitors the baby's oxygenation by observing it's heart rate"

d. "It monitors the baby's oxygenation by observing it's heart rate"

The amniotic membranes rupture during the labor of a client with breech presentation. Meconium is present in the amniotic fluid. The client asks the nurse what this means. What is an appropriate response by the nurse? a. "This often happens with a prolonged birth" b. "This indicates a blood incompatibility" c. "This is a sign of fetal distress" d. "This is normal in a breech birth"

d. "This is normal in a breech birth"

Nurse is caring for a client following vaginal birth. How much blood would indicate need for intervention 24 hours postpartum? a. 100 ml b. 200 ml c. 300 ml d. 500 ml

d. 500 ml

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is saturated with lochia rubra. What action should the nurse take first? a. Vigorously massage the fundus b. Call HCP immediately c. Have the charge nurse review the assessment d. Ask the client when she last changed her perineal pad

d. Ask the client when she last changed her perineal pad

What is the nurse's priority to regulate the temperature of a neonate? a. Supply extra heat sources to the neonate b. Keep ambient temperature less than 100 'F c. Minimize the energy needed for the neonate to produce heat d. Block radiant, convective, conductive and exaporative losses

d. Block radiant, convective, conductive and exaporative losses

Immediately after birth a nurse assesses neonates respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish and his HR is 130 bpm. Which step should the nurse take next? a. Tell the provider the neonate appears abnormal b. Assign an Apgar score of 8 c. Wrap the infant in a warm blanket d. Provide oxygen and stimulate the baby to cry

d. Provide oxygen and stimulate the baby to cry

The nurse interacts with a neonate who is experiencing drug withdrawal. Which finding indicates to the nurse the neonate has problems with autonomic regulation? a. Gaze aversion b. Body arching c. Sleep-wake disturbances d. Yawning

d. Yawning

A client with gestational hypertension is experiencing abdominal pain and vaginal bleeding. Which assessment should the nurse perform first? a. Fetal heart tones b. Strength of contractions c. Urinary output d. Serum electrolytes

a. Fetal heart tones

The nurse assesses a 3 week old neonate to determine hydration status. Which assessment finding is the best indicator of adequate hydration? a. Soft, smooth skin with good turgor b. A 2lb 3oz weight gain c. A HR of 120 bpm d. 2ml/kg/hr urine output

a. Soft, smooth skin with good turgor

A nurse is explaining physiologic hyperbilirubinemia to the parents of a neonate. Which statement by the parents would indicate correct understanding? a. "The neonate usually has this problem" b. "In term neonates, it usually appears after 24 hrs" c. "It is caused by elevated conjugated bilirubin lvls" d. "It is usually progressive from the neonates feet to his head"

b. "In term neonates, it usually appears after 24 hrs"

A client who has developed gestational diabetes mellitus during pregnancy has just been admitted in the L&D unit. What is the priority nursing action for this client? a. Ask the client about her most recent blood glucose levels b. Prepare oral hypoglycemic medications for administration during labor c. Notify NICU that a client with diabetes has been admitted d. Prepare the client for a Cesarean birth

a. Ask the client about her most recent blood glucose levels

On completing a fundal assessment, the nurse notes the fundus is firm and left of midline. What is the appropriate action? a. Ask the client to empty her bladder b. Straight catheterize the client immediately c. Call HCP for direction d. Vigorously massage the fundus

a. Ask the client to empty her bladder

The nurse is interviewing a client diagnosed with mastitis. which information would require further intervention by the nurse? a. Breastfeeding every 6 hours b. Breastfeeding affected breast first c. Increasing daily fluid intake d. Emptying the affected breast completely with each feeding

a. Breastfeeding every 6 hours (Should breastfeed every 2-3 hours to avoid milk stasis)

A postpartum mother is concerned about a noted decrease in milk production. Which response by the nurse best addresses this concern? a. Decrease supplemental feedings with formula b. Suggest the mother consume a diet high in vitamin C c. Have several alcoholic beverages for relaxation d. Feed the infant less frequently

a. Decrease supplemental feedings with formula

A mother tells the nurse she understands breastfeeding the best but will change to formula feedings when she returns to work in a few weeks. What should the nurse tell the mother about formula feedings? a. "All babies should be started on soy-based formulas to reduce the risk of allergies in the future" b. "When mixing the powdered formula, be sure to follow the manufacturers instruction to ensure proper nutrition" c. "All babies on formula should have iron-fortified formula to ensure healthy brain growth" d. " A brand name formula should be used because it has the best nutritional value" e. "Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding"

b. "When mixing the powdered formula, be sure to follow the manufacturers instruction to ensure proper nutrition" c. "All babies on formula should have iron-fortified formula to ensure healthy brain growth" e. "Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding"

The nurse is assessing a postpartum client who has lochia serosa. The client asks the nurse how long she should expect this type of bleeding. What is an appropriate response by the nurse? a. "days 3-4 postpartum" b. "days 3-10 postpartum" c. "days 10-14 postpartum" d. "days 14-42 postpartum"

b. "days 3-10 postpartum" (Lochia rubra lasts 1-3 days, lochia alba may last 2-6 weeks)

During a vaginal examination of a client in labor, it is determined that the biparietal diameter of the fetal head has reached lvl of ischial spines. How should the nurse document this finding? a. -1 b. 0 c. +1 d. +2

b. 0

Nurse is teaching client about the stages of labor. The client demonstrates an understanding of the teaching when she states that birth occurs during the: a. 1st stage b. 2nd stage c. 3rd stage d. 4th stage

b. 2nd stage

A nurse is caring for full term infant who is receiving phototherapy. The nurse determines immediate intervention is needed when the infant exhibits: a. Maculopapular rash b. Absent Moro reflex c. Greenish stools d. Bronze-colored skin

b. Absent Moro reflex (with lethargy and seizures are symptoms of bilirubin encephalopathy)

The nurse wraps a neonate in a blanket and keeps the ambient temperature warm. Which type of heat loss is this nurse trying to prevent? a. Conduction b. Convection c. Evaporation d. Radiation

b. Convection

Nurse is talking to patient who delivered baby 5 days ago and suspects the patient is experiencing postpartum blues. Which behavior is suggestive of this problem? (Select all that apply) a. Inability to care for the baby b. Crying c. Difficulty sleeping d. Voicing feelings of worthlessness e. Mood swings

b. Crying c. Difficulty sleeping e. Mood swings

While assessing a 2 hr old neonate the nurse observes the neonate to have acrocyanosis. Which nursing action should be done first? a. Give the baby a warm bath b. Do nothing different because this is a normal finding in the early newborn period c. Take temperature according to policy d. Notify HCP for cardiac consult

b. Do nothing different because this is a normal finding in the early newborn period

A non-stress test is ordered for a client with preeclampsia. The nurse is aware this test will be performed to assess a. anemia in the fetus b. Fetal well-being c. Intrauterine-growth-retardation (IUGR) d. Oligohydraminos

b. Fetal well-being

A neonate has developed a major infection. Which bacteria most likely contributed to the problem? a. E-Coli b. Group B Strep c. Klebsiella d. Pseudomonas

b. Group B Strep

A nurse is aware a neonate undergoing phototherapy needs to be monitored for: a. Sunburn b. Increased insensible water losses c. Decrease in platelet count d. The amount of light penetrating the tissue

b. Increased insensible water losses

The nurse is caring for a laboring client who presents with hypertension of pregnancy. The nurse is concerned the client may be developing preeclampsia when she notes: a. Decreasing BP b. Increasing oliguria c. Decreasing edema d. Trace levels of protien in the urine

b. Increasing oliguria

The nurse is assessing a client with type 1 diabetes. The client has developed an infection. The nurse should assess this client for: a. Anemia b. Ketoacidosis c. Respiratory acidosis d. Respiratory alkalosis

b. Ketoacidosis

A client is admitted with blood flowing down her legs. What would be the priority nursing action? a. Place an indwelling catheter b. Monitor fetal heart tones c. Perform a cervical examination d. Prepare client for cesarean birth

b. Monitor fetal heart tones

A client with gestational diabetes has just delivered a 10lb 2oz (4,601g) neonate at 39 weeks gestation. Which nursing intervention would be priority? a. Teach the mother about the nutritional needs of the neonate b. Obtain a serum neonatal glucose lvl c. Feed the infant a D50W solution d. Prepare to administer insulin to the neonate

b. Obtain a serum neonatal glucose lvl

A nurse is caring for a client exhibiting mild contractions and cervical dilation of 4cm. Using external fetal monitor the nurse observes variable decelerations. Which action should be taken first? a. Prepare for imminent birth b. Place the client on her left side c. Administer oxygen by face mask d. Increase the IV rate

b. Place the client on her left side (Variable decelerations are caused by compression of the umbilical cord and left side to relieve pressure)

The nurse is attending the delivery of a neonate at 38 weeks gestation. Prioritize the nurses interventions for this neonate. a. Place a cap on the neonate's head b. Preheat the radiant warmer prior to delivery c. Obtain an axillary temperature d. Wrap the neonate in new blankets e. Dry the infant with new blankets

b. Preheat the radiant warmer prior to delivery e. Dry the infant with new blankets d. Wrap the neonate in new blankets a. Place a cap on the neonate's head c. Obtain an axillary temperature

A nurse is about to give a client with type 2 diabetes her insulin before breakfast on her 1st day postpartum. Which client statement indicates an understanding of insulin requirements immediately postpartum? a. "I will need less insulin now than during my pregnancy" b. "I will need more insulin now than during my pregnancy" c. "I will need less insulin now than before I was pregnant" d. "I will nee more insulin now than before I was pregnant"

c. "I will need less insulin now than before I was pregnant" (Occasionally clients need little to no insulin within first 24-48 hrs after birth)

A nurse is teaching a client about kegel exercises. The nurse determines the teaching has been effective when the client states: a. "They assist with lochia removal" b. "They promote the return of normal bowel function" c. "They promote blood flow, and allow for healing and strengthening of the musculature" d. "They assist the mother in burning calories for rapid postpartum weight loss"

c. "They promote blood flow, and allow for healing and strengthening of the musculature"

Which neonate is most at risk for a problem with thermoregulation? a. A baby born to a mother with diabetes b. A baby born at 36 weeks gestation c. A baby born at 29 weeks gestation d. A baby at 36 hours of age with signs of jaundice

c. A baby born at 29 weeks gestation

A nurse is caring for 4 infants, which one is most likely to develop hyperbilirubinemia? a. An infant to a black mother b. An infant of an Rh positive mother c. An infant with an ABO incompatibility d. An infant with Apgar scores of 8 and 9 at 1 and 5 minutes

c. An infant with an ABO incompatibility

A client arrives in labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning? a. Total weight gain of 30 lbs (13.6kg) b. Maternal age of 32 yrs c. BP of 146/90 mmHg d. Treatment of syphilis at 15 weeks gestation

c. BP of 146/90 mmHg

The nurse describes cardinal mechanisms of labor while teaching an antepartum client about the passage of the fetus through the birth canal during labor. Place the events in proper sequence as they would occur: a. Flexion b. External rotation c. Descent d. Expulsion e. Internal rotation f. Extension

c. Descent a. Flexion e. Internal rotation f. Extension b. External rotation d. Expulsion

A nurse is teaching neonate umbilical cord care to a new mother at a birthing center. Which information should the nurse include: a. Apply alcohol to the word with each diaper change until the infant is 1 week old b. Clean the cord with chlorhexidine each time the diaper is changed until neonate is discharged c. Do nothing to the cord but keep it dry and open to air d. Wash the cord with soap and water each day until the cord falls off

c. Do nothing to the cord but keep it dry and open to air

At 39 weeks gestation a primiparous client arrives at unit reporting lower back pain that started 6 hours ago. A pelvic exam reveals cervix is dilated 3cm and 75% effaced. Which action would be appropriate? a. Instruct the client to push b. Send the client back home c. Monitor FHR d. Assess the lochia

c. Monitor FHR (Client is in the latent phase)

A client reports increasing severity of after-pains. What condition should the nurse look for in the client's history that may explain this symptom? a. Bottle feeding b. Diabetes c. Multiple gestation d. Primiparity

c. Multiple gestation

A client states she needs to void 3 hrs after a vaginal birth. Which risk factor would require the nurse to assist the client while getting out of bed? a. Afterpains b. Breast engorgement c. Orthostatic hypotension d. Painful episiotomy incision

c. Orthostatic hypotension

A neonate born to a mother who received magnesium sulfate during labor, which finding would be of most concern to the nurse? a. Apgar score of 7 b. Hypotonia c. Respiratory rate of 10 d. Heart rate of 104

c. Respiratory rate of 10

Which sign is the nurse's earliest indication of respiratory distress syndrome in a neonate? a. Bilateral crackles b. Pale grey color c. Tachypnea more than 60 breaths per minute d. Poor capillary refill

c. Tachypnea more than 60 breaths per minute

The nurse assesses a neonate for signs of infection. Which early finding would indicate the possibility of an infection? a. Hypotension b. Neurologic hyperactivity c. Temperature instability d. Thrombocytopenia

c. Temperature instability

A client at 42 weeks has a FHR of 160-190 bpm, the client states her baby is extremely active, uterine contractions are strong, occurring every 3-4 minutes and lasting 40-60 seconds. Which finding would indicate fetal hypoxia in this situation? a. Abnormally long uterine contractions b. Abnormally strong uterine contractions c. Increased frequency of contractions, with rapid fetal movement d. Excessive fetal activity and fetal tachycardia

d. Excessive fetal activity and fetal tachycardia

A patient requests her baby be sent back to the nursery on the 1st postpartum night so she can get some sleep. Which postpartal phase is the client experiencing? a. Depression phase. b. Letting-go phase c. Taking-hold phase d. Taking-in phase

d. Taking-in phase (Mom concerned about her own needs and requires help from staff and relatives)

A nurse is caring for a breastfeeding client who had a cesarean birth. What is the most important information for the nurse to teach this client? a. Delay breastfeeding until 24hrs after birth b. Breastfeed frequently during the day and every 4-6hrs at night c. Use the cradle hold position to avoid incisional discomfort d. Use the football hold to avoid incisional discomfort

d. Use the football hold to avoid incisional discomfort

A 6 week postpartum client is being assessed. The nurse notes the uterus is soft and enlarged, and the client is experiencing vaginal bleeding. The nurse is concerned the client is experiencing: a. Cervical laceration b. Clotting deficiency c. Perineal laceration d. Uterine subinvolution

d. Uterine subinvolution (Usually due to retained products of conception or infection)