Maternal Newborn Nursing
The nurse is preparing to teach a prenatal class about fetal circulation. Which statements housed be included in the teaching plan? Select all 1: the ductus arteriosus allows blood to bypass the fetal lungs 2: one vein carries oxygenated blood from the placenta to the fetus 3: the normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy 4: two arteries carry deoxygenated blood and waste products away from the fetus to the placenta 5: two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta
1, 2, 4
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contraction human immunodeficiency virus? select all 1: the client has a history of IV drug use 2: the client has a significant other who is heterosexual 3: the client has a history of sexually transmitted infections 4: the client has had one sexual partner for the past 10 years 5: the client has a previous history of gestational diabetes
1, 3
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1: therapeutic abortion is required 2: isoniazid plus rifampin will be required for 9 months 3: she will have to stay at home until treatment is completed 4: medication will not be started until after delivery of the fetus
2
An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: 1: Complete bed rest for the remainder of the pregnancy 2: Delivery of the fetus 3: Strict monitoring of intake and output 4: The need for weekly monitoring of coagulation studies until the time of delivery
2
The nurse is asking a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1: raise the head of the client's bed 2: obtain hemoglobin and hematocrit levels 3: instruct the client to request help when getting out of bed 4: inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided
3
The nurse is performing an assessment on a client who is at 38 week's gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1: document the findings 2: check the mother's heart rate 3: notify the health care provider 4: tell the client that the fetal heart rate is normal
3
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1: strict bed rest is required after the procedure 2: hospitalization is necessary for 24 hours after the procedure 3: an informed consent needs to be signed before the procedure 4: a fever is to be expected after the procedure because of the trauma to the abdomen
3
A non stress test is performed on a client who is pregnant, and the results of the test indicate non-reactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1: a normal test result 2: an abnormal test result 3: a high risk for fetal demise 4: the need for a cesarean section
1
The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determine that further teaching is needed if the client makes which statement? 1: I will need to increase my insulin dosage during the first 3 months of pregnancy 2: my insulin dose will likely need to be increased during the second and third trimesters 3: episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy 4: my insulin needs should return to prepregnant levels within 7-10 days after birth if I am bottle-feeding
1
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make? 1: you will need to bottle-feed your newborn 2: you will need to feed your newborn by nasogastric tube feedings 3: you will be able to breast-feed for 6 months 4: you will be able to breast-feed for 9 moths and then will need to switch to bottle-feeding
1
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1: 3 days postpartum 2: 7 days postpartum 3: on the day of birth 4: within 2 weeks postpartum
1
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? select all 1: age 54 2: BMI 28 3: previous difficulty with fertility 4: administration of oxytocin for induction 5: potassium level of 3.6
1, 2, 3
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? 1: allows for fetal movement 2: surrounds, cushions, and protects the fetus 3: maintains the body temperature of the fetus 4: can be used to measure fetal kidney function 5: prevents large particles such as bacteria from passing to the fetus 6: provides an exchange of nutrients and waste products between the mother and fetus
1, 2, 3, 4
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician
1
A pregnant client tells the clinic nurse that she wants to know the sex of the baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? 1: the appearance of fetal external genitalia 2: the beginning of differentiation in the fetal groin 3: the fetal testes are descended into the scrotal sac 4: the internal differences in males and females becomes apparent
1
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1:"What can I do for you?" 2:"Now you have an angel in heaven." 3:"Don't worry, there is nothing you could have done to prevent this from happening." 4:"We will see to it that you have an early discharge so that you don't have to be reminded of this experience."
1
The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1: we want to attend a support group 2: we never want to try to have a baby again 3: we are going to try to adopt a child immediately 4: we are okay, and we are going to try to have another baby immediately
1
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? select all 1: proteinuria 2: hypertension 3: low-grade fever 4: generalized edema 5: increased pulse rate 6: increased respiratory rate
1, 2
The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all 1: ballottement 2: Chadwick's sign 3: uterine enlargment 4: positive pregnancy test 5: fetal heart rate detected by a non-electronic device 6: outline of fetus via radiography or ultrasonography
1, 2, 3, 4
A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? 1: how often do you have sexual relations? 2: please share with me more about your concerns 3: you are still young and have nothing to be concerned about 4: you should not have a decline in testosterone until you are in your 80s
2
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? 1: did you ever have surgery 2: do you plan to have any other children 3: do either of you have diabetes mellitus 4: do either of you have problems with high blood pressure
2
A nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1: I will record the number of movements or kicks 2: I need to lie flat on my back to perform the procedure 3: if I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2-hours 4: I should place my hands on the largest part of my abdomen and concentrate on the fetal movements and count the kicks
2
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes
2
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1: come to the clinic immediately 2: the vaginal discharge may be bothersome, but is a normal occurrence 3: report to the emergency department at the maternity center immediately 4: use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours
2
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1: contact the health care provider 2: instruct the client to maintain bed rest for the remainder of the pregnancy 3: inform the client that these contractions are common and may occur throughout the pregnancy 4: call the maternity unit and inform them that the client will be admitted in a preterm labor condition
3
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the Fallopian tube for 3 days, what is the nurse's best response 1: it promotes the fertilized ovum's chances of survival 2: it promotes the fertilized ovum's exposure to estrogen and progesterone 3: it promotes the fertilized ovum's normal implantation in the top portion of the uterus 4: it promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone
3
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1: the client is measuring large for gestational age 2: the client is measuring small for gestational age 3: the client is measuring normal for gestational age 4: more evidence is needed to determine size for gestational age
3
The nurse is reviewing the health care provider's prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determine to be 37 weeks. Which prescriptions should the nurse question? 1: monitor fetal heart rate continuously 2: monitor maternal vital signs frequently 3: perform a vaginal exam every shift 4: administered antibiotic per HCP perception and per agency protocol
3
The nurse in a maternity unit is reviewing the client's records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? select all 1: a primigravida with mild preeclampsia 2: a primigravida who delivered a 10 lb infant 3 hours ago 3: a gravida 2 who has just been diagnosed with dead fetus syndrome 4: a gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5: a primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia
3, 5
Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1: it cushions and protects the baby. 2: it maintains the temperature of the baby. 3: it is the way the baby gets food and oxygen. 4: it prevents all antibodies and viruses from passing to the baby. 5: it provides an exchange of nutrients and waste products between the mother and developing fetus.
3, 5
The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus Which statement by the student indicates an understanding of the ductus venosus? 1: It connects the pulmonary artery to the aorta 2: it is an opening between the right and left atria 3: it connects the umbilical vein to the inferior vena cava 4: it connects the umbilical artery to the inferior vena cava
3.
The nurse evaluate the ability of a hepatitis B-positive mother to provide safe bottle-feeding other newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1: the mother requests that the window be closed before feeding 2: the mother holds the newborn properly during feeding and burping 3: the mother tests the temperature of the formula before initiating feeding 4: the mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding
4
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1: enlargement of the breasts 2: complaints of feeling hot when the room is cool 3: periods of fetal movement followed by quiet periods 4: evidence of bleeding, such as in the gums, petechiae, and purpura
4
The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measure. which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1: I should increase my sodium intake during pregnancy 2: I should lower my blood volume by limiting my fluids 3: I should maintain a low-calorie diet to prevent any weight gain 4: I should drink adequate fluids and increase my intake of high-fiber foods
4
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action? 1: document the findings 2: retake the temperature in 15 minutes 3: notify the healthcare provider 4: increase hydration by encouraging oral fluids
4
The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTTPAL, what should the nurse document in the client's chart?
G2 T1 P0 A0 L1
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of the her last normal menstrual period was 10/19/18. Using nagele's rule, what is the expected date of delivery?
July 26, 2019
The client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1: I will watch for the evidence of the passage of tissue 2: I will maintain strict bed rest throughout the remainder of the pregnancy 3: I will count the number of perineal pads used on a daily basis and notes the amount and color of blood on the pad 4: I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding
2
The maternity nurse is preparing the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has suspected diagnosis of placenta previa. The nurse review the health care provider's prescriptions and should question which prescription? 1: prepare the client for ultrasound 2: obtain equipment for a manual pelvic exam 3: prepare to draw a hemoglobin and hematocrit blood sample 4: obtain equipment for external electronic fetal heart rate monitoring
2
The nurse has created a plan of care for client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1: providing comfort measures 2: monitoring the fetal heart rate 3: changing the client's position frequently 4: keeping the significant other informed of the progress of labor
2
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abrupt placentae. Which assessment finding should the nurse expect to note if this condition is present? 1: soft abdomen 2: uterine tenderness 3: absence of abdominal blood 4: painless, bright red vaginal bleeding
2
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1: the client is a 35- yo primigravida 2: the client has a history of cardiac disease 3: the client's hemoglobin level is 13.5 4: the client is a 20 yo primigravida of average weight and height
2
The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1: your type of pelvis has a narrow pubic arch 2: your type of pelvis is the most favorable for labor and birth 3: your type of pelvis is a wide pelvis, but it has a short diameter 4: you will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery
2
A rubella titer result of a 1-day postpartum client is less than 1:8 and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all 1: breast-feeding needs to be stopped for 3 months 2: pregnancy needs to be avoided for 1 to 3 months 3: the vaccine is administered by the subcutaneous route 4: exposure to immunosuppressed individuals needs to be avoided 5: a hypersensitivity reaction can occur if the client has an allergy to eggs 6: the area of the injection needs to be covered with a sterile gauze for 1 week
2, 3, 4, 5
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which of the potential client needs should the nurse anticipate? select all 1: bed rest as a necessary preventive measure may be prescribed 2: routine administration of subcutaneous heparin may be prescribed 3: an overbid lift may be necessary if the client requires a cesarean section 4: less frequent cleansing of a cesarean incision, if present, may be prescribed 5: thromboembolism stockings or sequential compression devices may be prescribed
2, 3, 5
A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1: I should stay on the diabetic diet 2: I should perform glucose monitoring at home 3: I should avoid exercise because of the negative effects on insulin production 4: I should be aware of any infections and report signs of infection immediately to my health care provider
3
A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? 1.Disseminated intravascular coagulation 2.Chronic hypertension 3.Infection 4.Hemorrhage
4
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a c section birth, what is the most important nursing action? 1: slow the IV flow rate 2: continue the oxytocin drip if infusing 3: place the client in a high fowlers position 4: administer oxygen 8-10L via face mask
4
The home care nurse visits a pregnant cline two has a diagnosis of mild preeclampsia. Which assessment findings indicates a worsening of the preeclampsia and the need to notify the health care provider? 1: urinary output has increased 2: dependent edema has resolved 3: blood pressure reading is at the prenatal baseline 4: the client complains of a headache and blurred vision
4
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1: maternal fatigue 2: coordinated uterine contractions 3: progressive changes in the cervix 4: persistent nonreassuring fetal heart rate
4
The nurse is performing an assessment on a client diagnosed with placenta prevue. Which assessment findings should the nurse expect to note? select all 1: uterine rigidity 2: uterine tenderness 3: severe abdominal pain 4: bright red vaginal bleeding 5: soft, relaxed, contender uterus 6: Fundal height may be greater than expected for gestational age
4, 5, 6