MATERNAL 5
A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention? Select one: a. Reassess client in 30 minutes b. Begin an oxytocin infusion c. Assist client to void d. Assess lochia
c. Assist client to void A displaced and boggy uterus most likely indicate a full bladder and assisting the client to void would have the highest priority.
Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Select one: a. Hold and comfort the infant to stop the crying. b. Feed the infant oral feeding. c. Perform a heel stick to check serum glucose. d. Obtain an order for a drug screening blood test.
c. Perform a heel stick to check serum glucose. The priority action is to confirm the serum glucose before proceeding. A blood glucose level less than 40-45 mg/dL by heel stick is an urgent situation requiring therapy with glucose - generally orally.
A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? Select one: a. The drug is having a therapeutic effect b. The medication dose should be decreased c. The medication dose should be increased d. Deep tendon reflexes should be assessed a. The drug is having a therapeutic effect
A cessation of labor is the desired therapeutic effect of a tocolytic.
A client who is 32 weeks pregnant presents to the emergency room with bright red vaginal bleeding for the last 3 hours. The client reports feeling fetal movement since the bleeding started. Which of the following is the nurse's priority action? Select one: a. Assess maternal vital signs b. Assess fetal heart tones c. Perform a vaginal exam d. Administer a 500 mL fluid bolus
a. Assess maternal vital signs Since the client is feeling the baby move the most important step would be to establish baseline vital signs to determine potential blood loss and signs of shock.
The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? Select one: a. In true labor the cervix will dilate and efface b. In true labor walking will cause contractions to slow down c. In true labor the presenting part is engaged d. In true labor contractions are felt in the abdomen above the umbilicus
a. In true labor the cervix will dilate and efface Progressive changes in dilation and effacement are the ultimate signs of true labor.
A client diagnosed with pregnancy induced hypertension (PIH) has been receiving a Magnesium Sulfate infusion for three days. Serum drug levels have been between 8-10 mg/dl. Which of the following finding should the nurse expect to assess in the infant after delivery? Select one: a. Lethargy and respiratory depression b. Hypothermia and bradycardia c. Tachycardia and respiratory distress d. Hyperactivity and irritability
a. Lethargy and respiratory depression Mag. Sulfate blocks Neuromuscular transmission and is a CNS depressant. Therefore the infant will exhibit the same signs we assess for in a pregnant client receiving Magnesium: lethargy and respiratory depression. Therapeutic levels of Mag. Sulfate are 4-8mg/dl.
A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? Select one: a. Offer the neonate breast milk or formula b. Place the neonate under a radiant warmer c. Administer subcutaneous insulin d. Provide oxygen via oxyhood
a. Offer the neonate breast milk or formula A neonate of a diabetic mother is at risk for hypoglycemia. High glucose loads are present in the infant in utero. When maternal blood glucose via the placenta abruptly stops at birth, the neonate experiences a rapid drop in blood sugar. Signs of hypoglycemia in the neonate are jitteriness, lethargy, poor muscle tone, apnea, high pitched cry, and vomiting. Nursing interventions should focus on monitoring for sign of complications associated with hypoglycemia.
The nurse is observing sibling adaptation behaviors to the newborn infant during a family visit. To facilitate sibling acceptance, which action by the parents can assist with bonding? Select one: a. Provide the sibling a stuffed animal that they care for while the parents nurture the newborn. b. Discuss with the sibling the importance of being more independent. c. Encourage the sibling to spend time primarily with the babysitter. d. Create new traditions and routines.
a. Provide the sibling a stuffed animal that they care for while the parents nurture the newborn. this will help the sibling feel they are a part of the new family experience.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? Select one: a. The purpose of the NST is to assess the fetal CNS. b. The purpose of the NST helps to determine gestational age. c. The purpose of the NST is to determine fetal lie. d. The purpose of the NST is to determine fetal breathing.
a. The purpose of the NST is to assess the fetal CNS. This is the primary purpose of a NST. The test monitors the response of the FHR to fetal movement. This allows the nurse to assess the FHR in relationship to the fetal movement
A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? Select one: a. Unilateral stabbing abdominal lower abdominal pain. b. Absence of fetal heart tones and fetal movement. c. Steady bleeding with lower abdominal pain. d. Edematous face, hands, and ankles.
a. Unilateral stabbing abdominal lower abdominal pain. As the fetus develops, it eventually exceeds the diameter of the fallopian tube and ruptures the tube, creating an internal hemorrhage. There may or may not be blood from the vagina. The symptoms may include unilateral stabbing pain and tenderness in the lower abdominal quadrant, and commonly referred shoulder pain from blood irritation of the diaphragm or phrenic nerve. There may be nausea and vomiting, and symptoms of shock.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "What happens to your contractions when you move about?" d. "Have you felt fetal movement over the last 24 hours?"
b. "Have you noticed any bloody show or fluid coming from your vagina?" Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Telling the client to walk is not a correct response because it is an intervention rather than an assessment question.
A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? Select one: a. "When the baby is born, my thumb print will be taken along with the baby's footprint." b. "We will need to remove the baby's ankle identification band during diaper changes." c. "We will request to see picture identification badges for all facility staff who care for our baby." d. "When the baby is returned to us from the nursery, we should check the baby's identification band."
b. "We will need to remove the baby's ankle identification band during diaper changes." This statement indicates a need for further education. The mother, newborn, and significant other are identified by plastic identification bands with permanent locks that must be cut to be removed. Per most hospitals' policies, newborns will be provided with both ankle and armband identification. These identification bands should not be removed for any reason until the newborn is discharged from the hospital.
A nurse is assessing a client during her first prenatal visit. The client reports that her last normal period began on April 22. Use Nagele's rule to calculate this client's expected date of birth (EDB). Use the MMDD format to enter exactly four numerals, with no spaces or punctuation between the numbers. Select one: a. 0729 b. 0129 c. 0122 d. 0722
b. 0129 To use Nagele's rule subtract 3 months and add 7 days to the first day of the client's last normal menstrual period.
A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an appropriate psychological task for the client? Select one: a. Verbalize concerns about the health care facility b. Accept the fact that she is pregnant c. Begin to think about names for the baby d. View morning sickness as tolerable
b. Accept the fact that she is pregnant The developmental task during the first trimester is to accept the reality of the pregnancy. Accepting the reality of being pregnant allows the client to see a provider and get prenatal care.
A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? Select one: a. Negative Startle reflex b. Hypothermia c. Increased drowiness d. Diminished tendon reflexes
b. Hypothermia Thermal regulation issues are noted with this condition, such as hypothermia or hyperthermia. the neonate will demonstate increase wakefulness, sleep pattern disturbances and shrilled high-pitched cries.
A breastfeeding mother develops engorgement on her second postpartum day. Which of the following statements by the client indicates a need for further teaching? Select one: a. I will apply warm packs to each breast prior to feeding. b. I will offer my baby a bottle following each feeding. c. I will feed my baby every 2 hours. d. I will use a breast pump if my breasts do not soften.
b. I will offer my baby a bottle following each feeding. Bottle feeding while breastfeeding could lead to nipple confusion and interfere with successful breastfeeding. This mother needs further teaching. For breast engorgement, apply cool compresses between feedings and apply warm compresses or take a warm shower prior to breastfeeding.
A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? Select one: a. Increased size of neonate's heart. b. Maternal history of cytomegalovirus. c. A decreased number of functional alveoli. d. Documented birth trauma.
b. Maternal history of cytomegalovirus. Cytomegalovirus can be transferred via the placenta directly onto the fetal circulatory system and transmitted directly from infected amniotic fluid.
Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? Select one: a. Stop the oxytocin infusion and administer terbutaline 0.25 mg. b. Stop oxytocin infusion and assess contractions and fetal heart rate. c. Notify provider and prepare for an emergency cesarean birth d. Assess vital signs and apply O2 via facemask.
b. Stop oxytocin infusion and assess contractions and fetal heart rate. There is no indication that the mother or baby are in respiratory distress
A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is the correct position? Select one: a. Lithotomy position with a foam wedge behind the shoulders. b. Supine position with foam wedge positioned under one hip. C c. Modified Trendelenburg position with a foam wedge under the legs. d. Left lateral position with a foam wedge between the legs.
b. Supine position with foam wedge positioned under one hip. The supine position is appropriate for abdominal surgery (cesarean birth), and a wedge under one hip laterally tilts the client and reduces uterine weight on the vena cava and descending aorta. This helps maintain optimal perfusion of oxygenated blood to the fetus during the procedure.
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following? Select one: a. The taking-hold phase of maternal psychosocial adaptation. b. The taking-in phase of maternal postpartum adjustment. c. Postpartum role transition. d. Positive mother-infant bonding.
b. The taking-in phase of maternal postpartum adjustment. The taking-in phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn. The taking-hold phase of maternal postpartum adjustment begins on the second to third post-partum day and lasts 10 days to several weeks. The woman's focus is on exerting her independence in competently caring for her newborn. She may verbalize fears of incompetence or anxiety about exhaustion, and needs acceptance and encouragement. Postpartum depression may occur during this time.
a nurse is discussing the use of condoms with a female client. which of the following statements by client represents a need for further teaching? a. my partner will put the condom on while his penis is erect b. i will remove the condom 30 mins after intercourse c. my partner should should leave an empty space at the tip d. i can use spermicidal gels or creams to increase effectiveness
b. i will remove the condom 30 mins after intercourse
A postpartum client is reporting heavy vaginal blood flow. The nurse correctly understands which of the following assessments has the highest priority? Select one: a. Assess the client's last voiding b. Assessing vital signs both lying and sitting c. Assess the fundus for tone and position d. Assess episiotomy for bleeding
c. Assess the fundus for tone and position The most common cause of early post-partum bleeding is uterine atony. Even before assessing vital signs, the nurse should determine if the uterus is firm and midline in the abdomen. If it is not, fundal massage is urgently indicated, and if it is not midline, voiding is indicated, as a full bladder will displace the uterus and contribute to uterine atony
A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving Magnesium Sulfate IV. Which of the following assessment findings is the first sign of Magnesium toxicity? Select one: a. Respiratory depression b. Nausea and vomiting c. Decreased deep tendon reflexes d. Visual blurring
c. Decreased deep tendon reflexes Magnesium Sulfate reduces striated muscle contractions due to a depressant effect on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate include diminished tendon reflexes, hypotension and prolonged PR intervals. Later signs include absence of reflexes.
A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? Select one: a. The client is voiding 40 mL/hr b. The client reports feeling flushed and warm c. The client is drowsy and difficult to rouse d. The client's blood pressure is 130/70 mm Hg
c. The client is drowsy and difficult to rouse If the client is sleepy and difficult to rouse she may be experiencing symptoms of magnesium sulfate toxicity. This should be immediately reported to the provider.
A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? Select one: a. The fundus will be one centimeter above the umbilicus. b. The fundus will be two centimeters below the umbilicus. c. The fundus will be one centimeter below the umbilicus. d. The fundus will be at the level of the umbilicus.
c. The fundus will be one centimeter below the umbilicus. The fundus descends 1-2 cms per day, so from the highest point of 1 cm above the umbilicus at 12 hours, it should be 0 to 1 cms below the umbilicus on day two
a nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. which of the following statements by the parents indicated the need for further clarification? a i should not remove the yellow exudate on the end of the penis b i will clean his penis with each diaper change c the circumcision will heal completely within a couple of weeks d i can. give him a tub bath in two days
d) i can give him a tub bath in 2 days - newborns should not be immersed in water untill the circumcision has healed and the umbilical cord has detached
A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? Select one: a. B/P 110/60mmHg, trace protein, contractions every 3-4 minutes b. FHR 140 b/min: good variability, contractions every 3-4 minutes c. B/P 138/80mmHg, contractions every 3-4 minutes d. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes
d. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes Late decelerations are signs of placental insufficiency which can cause fetal hypoxemia. The nurse should notify PCP immediately.
A nurse is teaching a client the correct use a diaphragm as a method of contraception. Which of the following statements is correct? Select one: a. Douche promptly after removing the diaphragm b. Do not use any cream or jelly with the diaphragm c. Insert diaphragm at least 8 hours prior to sexual intercourse d. Leave diaphragm in place for at least 6 hours post coitus
d. Leave diaphragm in place for at least 6 hours post coitus The diaphragm should be left in place for at least 6 hours post intercourse.
A client in her first trimester is encouraged to increase intake of proteins and folic acid as essential nutrients for basic fetal growth. Which foods would the nurse identify as high in folic acid? Select one: a. Avocados b. Fish c. Tomatoes d. Lentils
d. Lentils this food is high in folate. Folic acid is crucial for neurological development and prevention of fetal neural tube defects. A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? Select one: a. "My baby's car seat should be in the back seat facing backwards." b. "I should always support my baby's head when I pick him up." c. "Once my baby begins to roll over it is okay to use a small pillow in the crib." c. "Once my baby begins to roll over it is okay to use a small pillow in the crib." It is never safe to have a pillow or a soft surface in the crib because of the danger of suffocation.
