Maternity Questions

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?

"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?

"I will flush the eyes after instilling the ointment."

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse would make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. Which is an appropriate nursing response?

"Surgical repair is usually around 6 to 12 weeks of age."

A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a primary health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur at this time. Which statement is true?

"Your normal insulin dosage will have to be decreased."

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How would the nurse respond to the client? Select all that apply.

-"Leopold's maneuvers are used to determine fetal position." -"Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." -"Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."

Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal? Select all that apply.

-Amniotic fluid pH is basic. -It is pale, straw-colored with flecks of vernix. -A volume of 1000 mL is an acceptable amount of amniotic fluid.

In caring for a preterm newborn, what knowledge related to skin care would the nurse consider when providing nursing care? Select all that apply.

-Skin of the preterm baby is thinner than that of the full-term infant. -A preterm baby has less subcutaneous fat than the full-term infant. -The posture of the preterm infant will expose more skin to potential heat loss. -The preterm infant has a high body surface area in relation to body weight.

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which signs as an indication of placental separation? Select all that apply.

-Sudden gush of dark blood from the introitus -Lengthening of the umbilical cord -Change in uterine shape

The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome? Select all that apply.

-Tachypnea -Retractions -Nasal flaring

The nurse is assisting in the admission of a woman for induction of labor. The nurse would contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.

-The fetus is in the breech position. -Lesions are present on the perineum. -The fetus is not settled into the pelvis.

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings would the nurse expect to note during data collection for this newborn? Select all that apply.

-The newborn is irritable. -The newborn cries incessantly. -The newborn is difficult to console. -The newborn hyperextends and postures.

The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply.

-The umbilical cord lengthens -Changes in the shape of the uterus -A trickle or gush of blood escapes from the introitus

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?

Abnormal palmar creases

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Determine the parents' desires for contact with the newborn.

The nurse is collecting data on a pregnant client in her 22nd week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action would the nurse take?

Document the assessment.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse would tell the mother that which is a sign of infection?

A moist cord with discharge

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding would the nurse expect to note in a healthy breast-feeding mother and newborn?

A mother breast-feeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action?

Administering oxygen via face mask

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?

Administration of immune globulin and vaccine in the infant soon after birth

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?

Ask about the newborn's blood type and direct Coombs.

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action would be to monitor which clinical parameter?

Blood glucose level

A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which findings in the infant?

Bounding radial pulses and absent or weak femoral and pedal pulses

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which action?

Clap the hand or slap on the mattress.

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Clean around the cord with plain water as needed until the cord falls off.

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest

The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse would instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?

Dried fruits

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket

When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?

Expression of hope for a positive outcome

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?

Fear of losing control

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which would be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?

Maternal vital signs

The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?

McRoberts' maneuver

The nurse is assigned to care for a client experiencing dystocia. Which is the highest priority in planning care?

Monitoring for changes in the physical and emotional condition of the mother and fetus

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse would take which action?

Notify the registered nurse of the finding.

The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Notify the registered nurse.

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse would monitor this client for which symptom of this complication?

Oozing from injection sites

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique would the nurse anticipate being used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

A client was admitted to the maternity unit 12 hours ago at station 0 and has been experiencing strong contractions every 3 minutes, and the fetus is currently still at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate?

Prepare the client for a cesarean delivery.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse would give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?

Providing the mother with pamphlets and booklets to read about the pregnancy

The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which would the nurse check first?

Pulse

The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, which nursing action can the nurse implement that will promote the birth of the placenta?

Putting the baby to the mother's breast and letting the baby suck

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time?

Rest between contractions

The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?

Resting interval of 50 seconds

The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy?

She has a history of chronic hypertension.

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?

Shoulder dystocia

The nurse in the newborn nursery is preparing to feed a non-breastfeeding newborn a first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these signs, the nurse might suspect that the newborn has which condition?

Tracheoesophageal fistula

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where?

Vulva

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?

Warming the crib pad before placing the newborn in the crib

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?

When was the last time the client ate or drank?

The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?

Decreased periods of uterine relaxation between contractions

During the intrapartum period, the nurse is caring for a laboring client diagnosed with sickle cell disease. The nurse recognizes that which conditions are most likely to lead to a sickling crisis? Select all that apply.

-Exertion -Infection -Hypoxemia -Dehydration

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse would monitor for which adverse effects of this medication? Select all that apply.

-Flushing -Depressed respirations -Extreme muscle weakness

Which nursing interventions would be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply.

-Monitor the temperature frequently. -Protect the eyes with an opaque mask. -Monitor and document the number and consistency of stools.

The nurse caring for a neonate that is 3 hours old would assess for which signs of cold stress? Select all that apply.

-Mottling of skin -Increased respirations with apnea

A 26-year-old woman comes to the clinic and asks for a pregnancy test because she thinks she might be pregnant. The nurse assesses for which presumptive signs of pregnancy? Select all that apply.

-No menstruation for the last 8 weeks -Early morning nausea -Breast tenderness

The nurse is collecting data on a 2-day-old newborn who was born with suspected Hirschsprung's disease. Which clinical manifestations support this diagnosis? Select all that apply.

-Refusal to feed -Visible peristalsis -The mother reports the infant has not had a bowel movement yet

A client asks, "What does it mean that the baby is at minus one?" The nurse would explain to the client that the fetal presenting part is which?

1 cm above the ischial spines

The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse indicates an understanding of a subdural hematoma?

Testing for equality of extremities when stimulating reflexes

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination would the nurse make?

The bright red bleeding is abnormal and should be reported.

The nurse is providing education to a client with gestational diabetes who was recently placed on insulin therapy. Which information would the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?

The insulin needs will increase.

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse would select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer would the nurse give to the mother?

The medication primarily decreases the number of apnea occurrences.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly.

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?

To bring the infant to the clinic

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges

A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which findings indicate a need to contact the registered nurse (RN)? Select all that apply.

-Blood pressure reading of 144/94 -Fetal heart rate of 180 beats per minute

A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply.

-Boardlike abdomen -Increase in fundal height

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.

-Constant fever of 101° F -Persistent pelvic heaviness -Foul-smelling vaginal discharge

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?

Changes in vital signs

The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breastfeeding.

A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions would the nurse provide to the mother?

Increase the frequency of the breast-feeding.

The postpartum nurse is caring for a mother whose blood type is O-negative and her newborn who is type A-positive. The nurse is drawing ordered labs on the mother and determines which laboratory test would provide the nurse with information about the mother's sensitization to fetal red blood cells?

Indirect Coomb's test

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?

Intravenous (IV) supplies

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse would encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action?

Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse would perform which action?

Prepare an ice pack for application to the area.

The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?

Provide pain relief measures.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic would the nurse expect to note?

Red

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data would best alert the nurse to early signs of hypovolemic shock?

Restlessness and agitation

The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which sign or symptom?

Signs of shock

The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply.

-Curtail exercise. -Measure your blood pressure daily. -Rest frequently by lying on your side. -Call the primary health care provider if you develop dizziness.

A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which would the nurse include in the instructions? Select all that apply.

-Eat a low-fat diet. -Stop or decrease smoking. -Eat smaller, more frequent meals. -Consume adequate fluid between meals.

The nurse is monitoring the status of a client in active labor. The nurse interprets that which findings are consistent with dystocia? Select all that apply.

-Signs of fetal distress -High level of maternal anxiety -Failure of the fetus to descend

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply.

-Urinalysis -Rubella titer -Complete blood count

The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.

-Urinary tract infections -Increased chance of cesarean birth -Delayed lung maturation in the neonate

A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply.

-Uterus soft to palpation -Bright red vaginal bleeding

A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia

The nurse would monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?

Longest period of fetal development

The nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC?

Swelling of the calf of one leg

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings would the nurse expect to note? Select all that apply.

-Bright red vaginal bleeding -Soft, relaxed, nontender uterus -Fundal height may be greater than expected for gestational age

A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.

-Clear fluid -White flecks in the amniotic fluid -Presence of glucose and protein in the amniotic fluid

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?

Lateral Sims'

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?

Contraction stress test

The nurse is caring for the nullipara woman in labor. The nurse understands that the primary health care provider must be contacted if which condition becomes apparent?

Decreased periods of uterine relaxation between contractions

A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding is noted if complete rupture occurs?

Decreasing blood pressure

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which would the nurse specifically monito

Deep tendon reflexes

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? Select all that apply.

-Bright red vaginal bleeding -Lack of uterine contractions

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply.

-Encourage frequent urination. -Continue maternal and fetal assessments. -Review breathing and relaxation techniques.

The nurse is collecting initial data on a newborn in the delivery room. Which observations would the nurse expect to note in a healthy newborn? Select all that apply.

-Respiratory rate of 40 breaths/minute -Three umbilical cord vessels, two arteries, and one vein

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones would the nurse identify as present at this time? Select all that apply.

-Sex recognizable -Blood forming in marrow -Kidneys able to secrete urine

The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply.

-Vaginal bleeding -Excessive vomiting -No fetal heart activity -Larger than normal uterine size -Elevated levels of human chorionic gonadotropin (hCG)