CMS Maternal Newborn Practice 2020 A

A nurse on a postpartum unit 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? a. provide fundal massage for the client b. Insert an indwelling urinary catheter for the client c. administer methylergonovine IM to the client d. Administer oxygen via nonrebreather face mask to the client

a. provide fundal massage for the client To increase uterine muscle tone and express blood clots from the uterus, which will decrease bleeding.

A nurse is reinforcing teaching with a client who is at 20 wks of gestation and has gestational diabetes mellitus. Which of the following information should the nurse include in the teaching? a. exercise before meals b. consume at least 2,000 cal/day c. avoid consuming an evening snack d. maintain a fasting blood glucose of 110 to 120 mg/dL

b. consume at least 2,000 cal/day This will ensure adequate glucose intake and prevent hypoglycemia. Exercise should be done after meals to prevent hypoglycemia. Should have an evening snack to prevent hypoglycemia during the night. Should maintain a fasting blood glucose of less than 95 mg/dL.

A nurse is caring for a client who is at 20 wks 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? a. weight b. fundal height c. fetal heart rate d. blood pressure

b. fundal height the same as week of gestation; plus or minus 2 cm

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? a. hyperglycemia b. hypertension c. urinary retention d. hyporeflexia

b. hypertension Can cause both hypertension and hypotension. as well as nausea, vomiting, cramping, headache and dizziness.

A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? a. 1 cup dried prunes b. 1/2 cup boiled potatoes c. 1/2 cup dried peas d. 1 cup grapes

c. 1/2 cup dried peas should consume 400 mcg of folate per 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? a. Some assistive personnel might not have name badges b. A nurse will carry my back to the nursery in their arms for routine care when it is needed c. I will ask the nurse to take my baby back to the nursery if I need to leave my room d. I can remove my baby's security band before giving her a bath

c. I will ask the nurse to take my baby back to the nursery if I need to leave my room Never leave the baby unattended. If the parent needs to leave the room, the parent should call the nurse to transport the newborn back to the nursery. - always wear identification - transported in a bassinet when moved from one location to another

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 the newborn? a. The client shakes powder from the container onto the newborn's skin b. The client uses a cotton-tipped swab to clean the newborn's ears c. The client washes the newborn's hair before unwrapping them d. The client rinses the newborn under warm, running water

c. The client washes the newborn's hair before unwrapping them Will help prevent heat loss. - running water means temperature can change, dangerous for newborn.

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? a. calcium 9.2 mg/dL b. Heart rate 160/min c. blood glucose 28 mg/dL d. axillary temperature 36.5 C

c. blood glucose 28 mg/dL normal 40-45 mg/dL - calcium 7.6 - 10.4 - fetal HR 110-160/ min, 80-100/min asleep, 180 when crying - axillary 36.5 - 37.5 F

A nurse on postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? a. place the client in high-Fowler's position b. administer terbutaline subcutaneously c. apply oxygen at 2 L/min via nasal cannula d. insert an indwelling urinary catheter

d. insert an indwelling urinary catheter - To monitor output closely. decreased kidney perfusion caused by shock can lead to oliguria. - apply oxygen at 10 L/min via non breather face mask - administer oxytocin medication such as oxytocin or methylergonovine, to increase uterine contraction. Terbutaline is a tocolytic that causes uterine relaxation, which will increase bleeding. - place client in a side-lying position or lying with the right hip elevated. client's leg should be elevated to at least a 30 degree angle to increase venous return.

A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect? a. Saturation of one perineal pad every 15 min b. Fundus 2 cm above the umbilicus c. Temperature of 39 C d. Urine output of 3,000 mL in 24 hr

d. urine output of 3,000 mL in 24 hr Should expect postpartum diuresis to begin approximately 12 hr after birth. - fundus should be 1 to 2 cm below the umbilicus; should ascend 1 cm per day after birth. - should not expect saturation of one perineal pad every 15 mins

A nurse is reinforcing teaching about car seat safety with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching? a. my baby should be in a rear-facing car seat until he is 6 months old and 15 lbs. b. if my baby rides in a car with no back seat, the passenger air bag must be turned off c. it is dangerous to secure the car seat using the vehicle's seat belts d. I will place my baby's car seat at a 90 degree angle in the back seat

b. if my baby rides in a car with no back seat, the passenger air bag must be turned off - cannot ride in the rear seat - keeping infants in a rear-facing car seat until they exceed the max height and weight for the car seat or are a minimum of 2 yrs of age - avoid placing the car seat at a 90 degree angle because it can compromise the newborn's airway. position so that the newborn at 45 degree angle.

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? a. I'll first need to see your photo ID before I can release the baby to you b. let me wash my hands and then I'll take the baby to his mother c. Please wash your hands first, then I'll allow you to carry the baby to your daughter's room d. Have your daughter call the nursery so that the staff can release the baby to you

b. let me wash my hands and then I'll take the baby to his mother Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns.

A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication? a. Fetal lung maturity b. maternal blood glucose control c. cessation of uterine contractions d. resolution of maternal nausea

c. cessation of uterine contractions nifedipine is a calcium channel blocker used to decrease uterine contractions by replacing the smooth muscle of the uterus - fetal lung maturity - glucocorticoid-dexamethasone - maternal blood glucose control - oral hypoglycemic agent - glyburide - help control blood glucose - resolution of maternal nausea - antiemetic - metoclopramide - decrease maternal nausea

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? a. Instruct the client to avoid crowds until a repeat hepatitis B test is negative. b. Tell the client that they will need to start the hepatitis B vaccine series after birth. c. Explain to the client that they will receive the hepatitis B immune globulin immediately. d. Inform the client that hepatitis B cannot be transmitted to the fetus

c. explain to the client that they will receive the hepatitis B immune globulin immediately - hepatitis B can cross the placenta and cause an infection in the fetus - should receive the hepatitis B vaccine series within 14 days of the last known exposure to the virus or following a positive test result. immunization is safe during pregnancy.

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? a. instruct the client to discontinue feeding from the affected breast b. tell the client to wear an underwire bra c. instruct the client to apply warm compresses to the affected breast d. Administer an antiviral medication

c. instruct the client to apply warm compresses to the affected breast - It will decrease inflammation and edema. It will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth. - plan to administer an antibiotic medication for about 10-14 days to eradicate the infection. - underwire bra can cause plugged milk ducts - should continue breastfeeding from both breasts because it will assist in emptying the breasts and decreasing pressure on the infected area.

A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse expect the provider to prescribe? a. indomethacin b. terbutaline c. methylergonovine d. betamethasone

c. methylergonovine Used to treat postpartum hemorrhage. An oxytoxic medication that causes contraction of the smooth muscle of the uterus, which assists in decreasing the loch. Should not be administered to clients who have preeclampsia or hypertension. - Indomethacin is an NSAID that relaxes smooth muscle of the uterus by inhibiting the production of prostaglandins. Indomethacin is used in the treatment of preterm labor. - Terbutaline is a tocolytic medication used in the treatment of preterm labor by relaxing the smooth muscle of the uterus - betamethasone is a glucocorticoid that is administered to promote fetal lung maturity in clients who are experiencing preterm labor.

A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy. Which of the following laboratory values should the nurse recognize as an indication that the therapy has been effective? a. glucose 45 mg/dL b. WBC count 10,000/mm3 c. total bilirubin 5 mg/dL d. hub 16g/dL

c. total bilirubin 5 mg/dL Phototherapy is used to treat newborns who have hyperbilirubinemia. normal is 1-12 mg/dL. - glucose: 30-60 - WBC: 9,000-30,000 - hemoglobin 14-24 g/dL

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? a. "I will massage my breasts while I take a shower." b. "I should wear an underwire bra during the day." c. "I should use a breast pump several times a day to relieve discomfort." d. "I will apply cold cabbage leaves to my breasts throughout the day."

d. "I will apply cold cabbage leaves to my breasts throughout the day." Should also apply ice packs or cold compresses to her breasts, take mild analgesics and wear a well-fitting and supportive bra.

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

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

Apical heart rate of 90/min while crying - normal range 110 - 160 for a newborn, heart rate of 80-100/min while asleep and up to 180/min while crying - Apneic episode of 20 seconds or less - normal; newborns respirations are normally shallow and irregular - Positive moro reflex present from birth up to 8 weeks - Vernix in the skin folds - normal

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

Blurred vision - indication of preeclampsia Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr, leg cramps

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? (select all that apply.) a. acrocyanosis b. tachypnea c. nasal flaring d. retractions e. expiratory grunting

b, c, d, e

A client requests information about the use of a diaphragm for birth control. Which of the following statements should the nurse make? a. you will need to replace your diaphragm every 2 years b. you can use an oil-based lubricant with your diaphragm c. you should have a full bladder when you insert diaphragm d. you should remove your diaphragm 1 hour after intercourse to clean it

a. you will need to replace your diaphragm every 2 years - Avoid baby oil, vaginal lubricants, mineral oil, and body lubricants because these can weaken the rubber of the diaphragm and reduce its effectiveness. - Should urinate and empty their bladder completely prior to inserting the diaphragm. - Should leave the diaphragm in place for at least 6 hr after intercourse because sperm remain viable in the vagina for that length of time.

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? a. 2+ urinary protein b. leukorrhea c. spider nevi d. 30 cm fundal height

a. 2+ urinary protein manifestation of preeclampsia. - spider nevi or vascular spiders - normal due to increase in estrogen production

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 gravidarum?

Ketonuria Occurs due to the breakdown of fat secondary to malnutrition or starvation Tachycardia and tachypnea due to dehydration

A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete?

Neonatal Abstinence Scoring System: exhibiting opioid withdrawal Additional manifestations: restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex - Apgar score: heart rate, respiratory rate, muscle tone, reflex irritability and skin color - Newborn Hearing Screen should be completed before the newborn is discharged from the hospital - Critical Congenital Heart Disease screen should be completed 24- 28 hours following birth and before the newborn is discharged from the hospital

A nurse is assisting in the care of a newborn immediately following birth. Which of the following images should the nurse identify as an indication that the newborn has a myelomeningocele?

Occurs when the neural tube fails to close, and the meninges and spinal cord herniate Occurs in the lumbar area and may be covered by a thin membranous sac - Exstrophy of the bladder; occurs from abnormal development of the abdominal wall, symphysis pubis and bladder ; visible in the suprapubic area and requires surgical intervention soon after birth - Omphalocel: occurs when abdominal organs herniate through the umbilical ring at the base of the umbilical cord - Cephalohematoma; collection of blood between the skull bone and its covering, the periosteum. A cephalohematoma does not cross the suture lines of the newborn's skull and will spontaneously resolve in 2-8 weeks

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

Place an opaque mask over the newborn's eyes - to prevent damage to the retinas - Should remove mask for feedings DO NOT apply a thin layer of lotion to the newborn's skin

A nurse is reinforcing teaching with a client who is at 20 wks of gestation and reports having constipation. Which of the following information should the nurse include? a. Consume 28 g of fiber per day b. decrease daily protein intake c. use laxatives daily d. drink 1 L of fluid per day

a. Consume 28 g of fiber per day

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. a client who is at 37 weeks of gestation and reports a persistent headache b. A client who is at 38 weeks of gestation and reports irregular uterine contractions c. A client who is at 12 weeks of gestation and reports abdominal cramping d. A client who is at 26 weeks of gestation and reports periodic numbness in the fingers

a. a client who is at 37 weeks of gestation and reports a persistent headache Persistent headache is a manifestation of preeclampsia - uterine contractions might be in the latent phase of labor - abdominal cramping may be experiencing a miscarriage - numbness in the fingers might be experiencing brachial plexus traction syndrome from drooping of the shoulders

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? a. check the newborn's blood glucose level b. Place the newborn under a radiant warmer c. Provide nonnutritive sucking d. swaddle the newborn

a. check the newborn's blood glucose level First action is to collect data from the client.

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 birth? Select all that apply a. diuresis b. soft, boggy uterus upon palpation c. discharge of clear, yellow fluid from the breasts d. Lochia serosa e. lower abdominal cramping

a. diuresis c. discharge of clear, yellow fluid from the breasts e. lower abdominal cramping - Soft, boggy uterus upon palpation can cause excessive bleeding - discharge of clear, yellow fluid is called colostrum, an expected finding in the postpartum period. present for 3-5 days until the mother's milk appears and can leak from the breasts beginning in the third trimester of pregnancy. - loch serosa is a vaginal discharge that is pink or brown, which occurs 3-4 days after birth

A nurse is reinforcing teaching with a client who has asked about continuing routine exercise during pregnancy. Which of the following responses should the nurse make? a. drink plenty of water after exercising b. lie on your back for 5 mins after exercising c. you should limit exercise to once per week d. increase your exercise intensity as your pregnancy progresses

a. drink plenty of water after exercising

A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching? a. the diaphragm should be removed 2 hours after having intercourse b. I can use water-soluble lubricant when my partner wears a latex condom c. It is okay for me to remove the birth control sponge within 2 hours after having intercourse d. When I use the birth control patch, it must be changed once a month

b. I can use water-soluble lubricant when my partner wears a latex condom - diaphragm should be left in in place for at least 6 hr following intercourse - contraceptive sponge should be left in place for at least 6 hr after intercourse - contraceptive patch is changed weekly for 3 weeks, followed by 1 week in which the client does not wear the patch

A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity. Select all that apply. a. hyperreflexia b. decreased respiratory rate c. polyuria d. decreased LOC e. double vision

b. decreased respiratory rate d. decreased LOC e. double vision As well as absent deep tendon reflexes, oliguria.

A nurse is reviewing the laboratory results of a 4-hr-old newborn. which of the following findings should the nurse report to the provider? a. hemoglobin 20 g/dL b. platelet count 120,000/mm3 c. Glucose 50 mg/dL d. WBC count 20,000/mm3

b. platelet count 120,000/mm3 normal range is 150,000 - 300,000 - hemoglobin: 14-24 g/dL - glucose: 30-60 mg/dL - WBC: 9,000-30,000/mm3

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? a. Begin giving approximately 240 mL (8 oz) per feeding after the first week. b. Position the bottle at a 45 degree angle during feedings c. Ensure that the newborn empties the bottle d. Wait to burp the newborn until the end of the feeding

b. position the bottle at a 45 degree angle during feedings To allow the newborn to have more control during feedings and prevent the swallowing of air. - reinforce to burp the newborn several times throughout the feeding as well as at the end of the feeding to relieve gas and decrease the risk for vomiting. - newborns will drink 15 to 30 mL of formula per feeding during the first 24 hr while gradually increasing intake as they grow. By the end of the second week of life, most newborns consume 90 to 150 mL of formula at each feeding.

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? a. facilitate the storage of iron in the fetus liver b. prevent certain kinds of birth defects c. inhibit premature labor d. aid in the absorption of other important nutrients

b. prevent certain kinds of birth defects

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? a. negative rubella titer b. reactive non stress test c. 1-hr glucose tolerance screening test result of 150 mg/dL d. Hemoglobin 9.5 g/dL

b. reactive non stress test Indicates fetal well-being and is desirable outcome.

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? a. we will monitor your blood pressure every 2 hours b. your fluid intake will be limited to no more than 125 milliliters per hour. c. You might notice that you will begin breathing faster than normal d. We will monitor your baby's heart rate once per hour

b. your fluid intake will be limited to no more than 125 milliliters per hour. - should take the client's BP every 15-30 mins - hypotension is an adverse effect - causes respiratory depression. monitor RR every 15 min

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? a. BUN 14 mg/dL b. platelet count 200,000/mm3 c. Hematocrit 30% d. creatinine 1.0 mg/dL

c. Hematocrit 30% normal greater than 33% - BUN: 10-20 mg/dL - platelet: 150,000-400,000/mm3 - creatinine: 0.5 - 1.0 mg/dL

A nurse is reinforcing home care safety with the guardian of a newborn prior to discharge. Which of the following statements by the guardian indicates understanding of the teaching? a. I can place a pillow in my baby's crib b. I can allow my toddler to sleep in the bed with my baby c. I should place my baby's crib away from windows d. I should keep my baby's bath water at 97 degrees Fahrenheit

c. I should place my baby's crib away from windows Away from windows to prevent drafts or entanglement in blinds or drapery. - bath temperature at 38-40 to prevent heat loss - Bed sharing during the first year can increase suffocation and SIDS

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? a. Eat foods that are served hot b. drink 360 mL (12 oz) of fluids during mealtimes c. consume small meals frequently d. eat a high-protein snack before getting out of bed

c. consume small meals frequently - Instruct to eat 5-6 small meals. Client should avoid an empty stomach, as this increases nausea. - eat high in carbohydrates such as crackers - avoid drinking liquid with meals, consumption of fluids and food every 2-3 hrs throughout the day

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? a. intramuscular b. intradermal c. subcutaneous d. topical

c. subcutaneous Terbutaline relaxes the smooth muscles and inhibits uterine activity. administered every 4 hr.

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? a. leg cramps b. tingling of fingers c. varicose veins d. epigastric pain

d. epigastric pain manifestation of preeclampsia

A nurse is collecting data from a client who is in the second trimester of pregnancy. Which of the following findings should the nurse report to the provider? a. Increased leukorrhea b. hyperpigmentation of the face c. varicose veins d. frequent uterine contractions

d. frequent uterine contractions These contractions can cause the cervix to open early and subject the client to preterm labor. - hyperpigmentation also known as the "mask of pregnancy" : normal

A nurse is caring for a client 6 hr 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? a. administer analgesics b. apply an ice pack to the perineum c. assist the client with breastfeeding d. help the client ambulate to the toilet

d. help the client ambulate to the toilet The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to assist the client to urinate and completely empty the bladder, which will allow the uterus to contract.

A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in newborns with a group of clients who are pregnant. Which of the following risk factors should the nurse include? a. cord compression b. chronic hypertension c. alcohol use during pregnancy d. prematurity

d. prematurity A newborn who is premature has inadequate surfactant production, which can lead to RDS. Alcohol syndrome can result in fetal alcohol syndrome, developmental delay, and birth defects. Cord compression can result in fetal anoxia.

A nurse is assisting with the care of a client who is at 40 wks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? a. maternal temperature of 37.5 C b. contractions every 3 min c. presence of bloody show d. prolonged deceleration of FHR

d. prolonged deceleration of FHR Because it can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse.

A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension with a client who is at 16 wks of gestation. Which of the following responses by the client indicates an understanding of the teaching? a. I will apply support stockings 30 minutes after getting out of bed b. I will lie on my left side with my head elevated on a pillow c. I will cross my legs when sitting d. I will limit my salt intake

b. I will lie on my left side with my head elevated on a pillow Should consume 1.5 to 2.3 g of salt per day.