Maternity / OB Exam 3 Practice Questions
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. Hand the parent the newborn, and suggest that they change the diaper B. Ask the parent why they are so anxious and nervous C. Tell the parent they will grow accustomed to the newborn D. Provide education about infant care when the parent is present
D
A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include? A. "Position the newborn at a 45-degree angle in the car seat." B. "Place the retainer clip across the newborn's abdomen." C. "Keep the car seat rear-facing until the newborn can sit unsupported." D. "Place the shoulder harness straps below the level of the newborn's armpits."
A
Which of the following are risk factors for postpartum hemorrhage? Select all that apply A. Sixth pregnancy, fifth delivery B. Large for gestational age infant (LGA) C. Vaginal method of delivery D. Use of magnesium sulfate E. Use of oxytocin after delivery
A, B, D
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? A. Perform a sharp hand clap near the infant. B. the newborn vertically allowing one foot to touch the table surface. C. Place a finger at the base of the newborn's toes. D. Turn the newborn's head quickly to one side.
A To elicit the Moro reflex, the nurse performs a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position.
A nurse is caring for a client who is one day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those family members E. Interprets the newborn's behavior as meaningful and a way of expressing needs.
A, C
A nurse on the postpartum unit is assessing a client who is being admitted with a suspected DVT. Which of the following clinical findings should the nurse expect? (Select all) A. Calf tenderness to palpation B. Mottling of affected extremity C. Elevated temperature D. Area of warmth E. Report of nausea
A, C, D
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? Select all that apply A. Document fundal height. B. Massage a firm fundus. C. Observe the lochia during palpation of fundus. D. Determine whether the fundus is midline. E. Administer methylergonovine maleate if uterus is boggy.
A, C, D, E
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (Select all) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments
A, C, E
A nurse is providing education to a client who is 2 hours postpartum and has perineal laceration. Which of the following information should the nurse include? (Select all) A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back and forth motion E. Apply cold or ice packs to perineum
A, C, E
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? A. Hepatitis B Immunization B. Haemophilus influenzae type B immunization (Hib) C. Lidocaine gel to the umbilical stump D. Vitamin K Injection E. Antibiotic ointment to both eyes
A, D, E
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care (Select all that apply) A. I'll expect the plastic ring to fall off by itself within a week B. I'll apply petroleum jelly to his penis with diaper changes C. I'll wash his penis with warm water and mild soap each day D. I'll call the doctor if I see any bleeding E. I'll make sure his diaper is loose in the front
A, D, E
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. The client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? A. Come back later when the client is more cooperative B. Give client time to express feelings C. Tell the client they need to be quiet so the assessment can be completed D. Redirect the clients focus so they will become quiet
B
A client is to be discharged this morning with their infant. Discharge teaching would include all the following except: A. Continue taking your prenatal vitamins B. Avoid using tampons, douching, or intercourse for 7-10 days C. Call your provider for any fever, significant increase in vaginal bleeding, or foul-smelling lochia D. Eat a well-balanced diet and increase your fluid intake
B
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A. Moderate lochia rubra B. Fundus three fingerbreadths above the umbilicus C. Moderate swelling of the labia D. Blood pressure 130/84 mm Hg
B
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? A. Caput succedaneum B. Cephalhematoma C. Molding D. Pilonidal dimple
B
A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? A. Babinski B. Rooting C. Moro D. Stepping
B
A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? A. I am likely to have a fever the first week I am home B. I will resume taking my prenatal vitamins C. I will call my provider if I have discharge from my incision D. I should not have unrelieved pain in my abdomen E. I will rest in a recliner until my incision is healed
B, C, D
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? A. Wash the cord daily with mild soap and water. B. Cover the cord with the diaper. C. Apply petroleum jelly to the cord stump. D. Give a sponge bath until the cord stump falls off.
D Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infection B. Retained placental fragments C. Thrombophlebitis D. Uterine atony
D A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? A. Obtain blood glucose by heel stick. B. Initiate phototherapy. C. Monitor the newborn's blood pressure. D. Place the newborn in a radiant warmer.
A
A nurse is providing discharge teaching for a non-lactating client. Which of the following instructions should the nurse include in the teaching? A. Wear a supportive bra continuously for first 72h B. Pump your breast every 4h to relieve discomfort C. Use breast shells throughout the day to decrease milk supply D. Apply warm compresses until milk suppression occurs.
A
A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse? A. Blood pressure 100/70 mm Hg B. Headache pain rated a 6 on a scale of 0 to 10 C. Respiratory rate 10/min D. Urinary output 30 mL/hr
C
A nurse is conducting a home visit for a client who is one week postpartum and breastfeeding. The client report breast engorgement. Which of the following recommendations should the nurse make? A. Apply cold compresses between feedings B. Take a warm shower right after feedings C. Apply breast milk to the nipples and allow them to air dry D. use the various infant positions for feedings.
A
A nurse is performing a fundal assessment for a client who is 3 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12cm with lochia that is bright red and contains small clots. Which of the following should the nurse document? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubrua D. Scant lochia serosa
A
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Deltoid
A
A nurse is caring for newborn and calculation the Apgar score. At 1 min after delivery, the following findings are noted: 110 HR, slow, weak cry, some flexion of extremities, grimace in response to suctioning of the nares. body pink in color with blue extremities. Calculate the newborn's score.
6
A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a HR of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?
8
A client who is breastfeeding is concerned their 3-day old infant is not getting enough to eat. Which of the following assessment findings indicates the infant is feeding well? A. The infant's stools are beginning to turn yellow B. The infant has not voided since birth C. The infant is nursing 4 times in 24 hours D. The client's breasts feel full after feedings
A
A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make? A. "It sounds like you are feeling sad that things didn't go as planned." B. "At least you know you have a healthy baby." C. "Maybe next time you can have a vaginal delivery." D. "You can resume sexual relations sooner than if you had delivered vaginally."
A
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
A
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. Increasing pulse and decreased BP B. Dizziness and increased RR C. Cool, clammy skin, and pale mucous membranes D. AMS and LOC
A
A nurse is teaching a client who is postpartum and has a new Rx of an injection of Rh0 (D) immunoglobulin. Which of the following should be included in the teaching? A. It prevents the formation of Rh antibodies in mothers who are Rh negative. B. It destroys Rh antibodies in mothers who are Rh negative. C. It destroys Rh antibodies in newborns who are Rh positive. D. It prevents the formation of Rh antibodies in newborns who are Rh positive.
A
L.K. is a G6 P5 client with severe preeclampsia on magnesium sulfate who has just given birth to a 39 week, 10 lb. 4 oz. male infant vaginally one hour ago. Upon assessment, the nurse notes the following: fundus 3cm above the umbilicus and boggy, large lochia rubra with small clots, T: 98.9, P: 110, R: 18, and BP 142/89. D5 ½ NS with 30 units of Pitocin is running at 75 mL/hr in addition to Magnesium sulfate running at 2g/hr (50 mL/hr). Blood type: A negative. GBS: positive; treated X2. Rubella: immune. Hepatitis B: nonreactive. What is the priority nursing action at this time? A. Massage the fundus B. Turn off the magnesium sulfate infusion C. Have the client void D. Check a hemoglobin and hematocrit
A
The nurse is reviewing the postpartum laboratory results for a client. The hemoglobin and hematocrit (H & H) are 8.8 and 27.9. Vital signs are: T: 98.2, P: 88, R: 18, and BP 132/85. Lochia is moderate red rubra; no clots. Which of the following orders would the nurse anticipate from the provider? A. Initiation of iron supplements B. 2 units of packed red blood cells (PRBCs) C. Methylergonovine maleate 0.2 mg IM now D. No new orders; this is a normal finding
A
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? A. Fundus firm to palpation B. Increase in blood pressure C. Increase in lochia D. Report of absent breast pain
A (Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.)
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."
A (Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.)
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. B. Notify the client's provider. C. Increase the frequency of fundal massage. D. Encourage the client to empty her bladder.
A (These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.)
A client gave birth 2 hours ago and the nurse notes the blood pressure is 60/50 mmHg. Which action first? A. Evaluate the firmness of the uterus B. initiate oxygen therapy by non-rebreather mask C. Administer oxytocin infusion D. obtain a type and crossmatch
A (This blood pressure can indicate postpartum hemorrhage so the nurse should see if there is a uterine atony. All of the other actions should be done but uterus assessment is first)
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? A. Clear the respiratory tract. B. Dry the infant off and cover the head. C. Stimulate the infant to cry. D. Cut the umbilical cord.
A Clearing the airway of the infant is the first action the nurse should take immediately following delivery.
A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? A. "My baby will be placed under special lights if the test result is positive." B. "My baby needs to be on formula or breast milk before the test can be done." C. "This test checks for a genetic disorder that can be managed by diet." D. "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up."
A Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? A. Respiratory distress B. Hypothermia C. Accidental lacerations D. Acrocyanosis.
A Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress.
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress B. Shivering C. Basal metabolic rate reduction D. Brown fat production
A When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.
A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility B. Physiologic jaundice C. Absence of vitamin K D. Maternal cocaine use
A most common form of pathologic jaundice; appears within the 1st 24 hrs of life. Physiologic jaundice appears after 24 hrs.
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30 min period. Which of the following is the priority nursing intervention at this time? A. Palpate the client's uterine fundus. B. Assist the client on a bedpan to urinate. C. Prepare to administer oxytocic medication. D. Increase the client's fluid intake.
A (Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client's fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone.)
A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of LR with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include BP 146/95, pulse 80, RR 18. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? A. Methylergonovine 0.2 mg IM now. B. Insert an indwelling urinary catheter. C. Administer oxygen by nonrebreather mask at 5 L/min. D. Obtain laboratory study of prothrombin and partial thromboplastin time.
A (Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification.)
A nurse is caring for a client who is experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? A. At the level of the umbilicus B. 2 cm above the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus
A (Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day. The uterus would be palpated at a position between the umbilicus and symphysis pubis in a client who is approximately 1 week postpartum.)
A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? Select all that apply A. Blot the perineal area dry after cleansing. B. Clean the perineal area from front to back. C. Perform hand hygiene before and after voiding. D. Apply ice packs to the perineal area several times daily. E. Wash the perineal area using a squeeze bottle of warm water after each voiding.
A, B, C, E (Ice packs may be applied to the perineal area for the first 24 to 48 hr to decrease edema and to provide an anesthetic effect. This would not be indicated after that time, nor does it provide any preventative benefits from infection)
A client is reporting unrelieved episiotomy pain 8hr after delivery. Which of the following actions should the client's nurse take? A. Apply an ice pack to the perineum. B. Offer a warm sitz bath C. provide a squeeze bottle of antiseptic solution D. place a hot pack to the perineum
A. During the first 24 hr, ice packs and cool water sitz baths should be used. This should reduce edema and reduce discomfort.
A nurse is completing discharge instructions for a new mother and her 2 day old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." B. "Your baby should wet 6 to 8 diapers per day." C. "Your baby should burp after each feeding." D. "Your baby should sleep at least 6 hours between feedings."
B
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of uterine atony. A. Poor involution B. Urinary retention C. Hemorrhage D. Infection
B
A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? A. Fundus soft, 1 cm to the right of the umbilicus B. Fundus firm, at the level of the umbilicus C. Fundus present, to the left of the umbilicus D. Fundus soft, 2 cm above the umbilicus
B
A nurse is caring for a client who is 2 days postpartum. The client states "My 4 year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. Your son was probably not ready for toilet training and should wear training pants B. Your son is showing an adverse sibling response C. Your son may need counseling D. You should try sending your son to preschool to resolve the behavior
B
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Ask another nurse to verify the heart rate. B. Document this as an expected finding. C. Call the provider to further assess the newborn. D. Prepare the newborn for transport to the NICU.
B
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. I will need to use contraception for 3 months before considering pregnancy. B. I need a second vaccination at my postpartum visit C. I was given the vaccine because my baby is O-positive D. I will be tested in 2 months to see if I have developed immunity
B
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? A. Sternal notch B. Nipple line C. Xiphoid process D. Fifth intercostal space
B
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended to a third-degree laceration B. A client who does not wash their hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation D. A client who has a c-section incision that is well-approximated with no drainage
B
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? A. "I will place my baby on his stomach when he is sleeping." B. "I should remove extra blankets from my baby's crib." C. "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." D. "I should place my baby's crib next to the heater to keep him warm during the winter."
B
One the 2nd day postpartum following a cesarean birth, a client exhibits hypotension, dyspnea, hemoptysis, and chest pain. The nurse recognizes these as signs and symptoms of which of the following complications? A. Endometritis B. Pulmonary emboli C. Hypovolemia D. Atelectasis
B
The nurse is caring for a postpartum client who has chosen to bottle feed. Which of the following points will the nurse include in teaching to promote lactation suppression? A. Apply warm compresses to the breasts B. Wear a tight-fitting bra C. Pump the breasts only bid D. Increase fluid intake
B
The nurse is educating a Graduate Nurse on appropriate fundal massage technique. Which of the following statements by the Graduate Nurse indicates understanding of correct fundal massage technique? A. Placing continuous two-handed pressure on the uterus until the bleeding stops B. One hand anchors the lower uterine segment while the other hand massages the fundus C. Placing one hand firmly on the fundus until clots are expressed D. Applying bimanual pressure to the uterus
B
Which of the following actions would the nurse include in the plan of care for a newborn receiving phototherapy? a. Keeping the newborn in the supine position b. Covering the newborn's eyes while under the phototherapy light c. Ensuring the newborn is covered and clothed d. Reducing the fluid intake to 6 ounces daily
B
A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in". Which of the following responses should the nurse make? A. Within 2 days B. In 3-5 days C. In 6-8 days D. In about 10 days
B (By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.)
A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? A. Saturated perineal pad in 30 min B. Deep tendon reflexes 4+ C. Fundus at level of umbilicus D. Approximated edges of episiotomy
B (Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding.)
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? A. Assist the family to identify prior use of positive coping skills in family crises. B. Ask the client if she has considered harming her newborn. C. Anticipate a prescription by the provider for an antidepressant. D. Reinforce postpartum and newborn care discharge teaching.
B (When using the nursing process in caring for a client, the first action should focus on assessment of the client's mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn.)
A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? A. Platelets 200,000/mm3 B. Bilirubin 19 mg/dL C. Blood glucose 45 mg/dL D. Hemoglobin 22 g/dL
B A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? A. Begin phototherapy. B. Initiate early feeding. C. Suction excess mucus with a bulb syringe. D. Prepare for an exchange blood transfusion.
B Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn's stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? A. 22/min B. 48/min C. 100/min D. 110/min
B The expected reference range for a newborn's resting respiratory rate is 30 to 60/min.
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? A. Suction the nose with a bulb syringe. B. suction the mouth with a bulb syringe. C. Use a suction catheter with low negative pressure. D. Turn the newborn on his side.
B The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three finger breadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? A. The client is exhibiting early indications of mastitis. B. Additional interventions are not indicated at this time. C. Application of a heating pad to the breasts is indicated. D. The client should be advised to remove her nursing bra.
B (For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range)
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? A. "You need to take pain medications so you are more comfortable." B. "We can time your pain medication so that you have an hour or two before the next feeding." C. "All medications are found in breast milk to some extent." D. "You have the option of not taking pain medication if you are concerned."
B This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse? A. "You may carry your grandchild to the room." B. "You can push the baby to the room in a wheeled bassinet." C. "Have the mother call and I will take the baby to the room." D. "If you show me your photo identification, you can take the infant."
C
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks at you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "the best way to determine if your baby can hear is to clap your hands loudly and see if she startles."
C
A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statement is a therapeutic response by the nurse? A. "I will call your primary care provider to report your concerns." B. "I will take your baby to the nursery for further examination." C. "This occurs because newborns lack muscle control to regulate eye movement." D. "This is a concern, but strabismus is easily treated with patching."
C
A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days
C
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. Scant, non odorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipples with cracks and fissures D. Decreased response to sexual activities.
C
A nurse is providing discharge instructions to a postpartum client following a c-section. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. Sit ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches
C
A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statement by the parent indicates understanding of the teaching? A. "I should start solid foods when my baby is 3 months old." B. "I should introduce cow's milk when my baby is 9 months old." C. "I should wait to give fruit juice until my baby is 6 months of age." D. "I should wait to begin fluoride supplements until my baby is 4 months of age."
C
A nurse on the l&d unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placing the newborn on a warm surface B. Preventing air drafts C. Drying the newborn's skin thoroughly D. Maintaining ambient room temperature at 24° C (75° F)
C
A postpartum client appears very pale and states they are bleeding heavily. Which of the following actions would the nurse take first? A. Call the provider immediately B. Administer Methylergonovine 0.2mg IM C. Assess the uterine fundus and determine when the client voided last D. Reassure the client this a normal postpartum finding
C
During ambulation to the bathroom a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse find the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being. A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow
C
The client's fundus is firm at midline at the level of the umbilicus. Moderate lochia rubra is present. The nurse notes in the chart the patient had a fourth degree laceration. Upon assessment, the nurse notes the wound edges are well-approximated, no redness, purulent drainage, ecchymosis, or active bleeding is noted. The labia are swollen and several hemorrhoids are present. What is the priority nursing consideration for this client at this time? A. Breastfeeding success B. Client perception of body image C. Client pain level D. Potential for constipation
C
The oncoming nurse is reviewing a client's labor and delivery data and notes that mom is type A negative and the infant is type A positive. Which of the following actions are appropriate for the nurse to take? A. Inform the client they have ABO incompatibility B. Monitor the infant closely for the development of hypobilirubinemia C. Call the provider and obtain an order for RhoGAM D. Administer the MMR vaccine
C
When assessing a term newborn at 6 hours old, the nurse auscultates bowel sounds and documents the recent passage of meconium stool. These findings would indicate which of the following? A. Abnormal gastrointestinal newborn transition and needs to be reported B. An intestinal anomaly that needs immediate surgery C. A patent anus with no bowel obstruction and normal peristalsis D. A malabsorption syndrome resulting in fatty stools
C
Which of following education about sexual activity would the nurse include in postpartum teaching? A. Interest in sexual activity may increase due to hormonal fluctuations B. Lubricants are unnecessary due to the increased vaginal mucus C. Sexual intercourse should be avoided until vaginal bleeding has ceased D. Natural family planning is the best method to avoid pregnancy in the postpartum period
C
A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? A. Moderate amount of dark red lochia with a bloody odor B. A localized area of breast tenderness C. Pelvic pain D. Hematuria
C (Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.)
A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis? A. Swelling in both breasts B. Cracked and bleeding nipples C. Red and painful area in one breast D. A white patch on a nipple
C (Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral)
A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching? A. "I will breastfeed every 2 hours." B. "I will apply ice packs to my breasts after feeding." C. "I should apply hot packs to my breasts during feeding." D. "I should crush cabbage leaves and place them on my breasts."
C (The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.)
A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? A. I will decrease my daily fiber intake B. I'll make sure I reduce salt in my diet C. I'll eat more protein at each meal D. I will consume more vitamin D-rich foods
C (during lactation, client should consume about 25 g of additional protein per day.)
A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statement by the client as an indication of inhibition of parental attachment? A. "He's got my husband's nose, that's for sure." B. "I don't need a baby bath demonstration. I know how to do it." C. "I wish he had more hair. I will keep a hat on his head until he grows some." D. "Do you think you could keep him in the nursery for the next feeding so I can get
C (This client statement expresses disappointment in the newborn's appearance and a need to hide what the client perceives as an undesirable feature. This is an indication of inhibited parental attachment.)
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? A. Flex her knee while resting B. Massage the area C. Elevate her leg D. Apply a cold compress
C (encourages venous return and relieves pain. Client should also apply moist heat to the affected area)
A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is a priority action by the nurse? A. Encourage parents to touch and explore neonates features B. Limit noise and interruption in the delivery room C. Place the neonate at the clients breast D. Position the neonate skin-to-skin on the client's chest
D
A nurse is planning care for a client who is 2 hrs postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? A. Apply warm, moist heat to the client's lower extremities. B. Massage the client's posterior lower legs. C. Place pillows under the client's knees when resting in bed. D. Have the client ambulate.
D
A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction? A. "I will keep my baby's head elevated while he is feeding." B. "I will allow my baby to burp several times during each feeding." C. "My baby will have soft, formed brown stools." D. "I will tip the nipple so air is present as my baby sucks."
D
Which of the following instructions would the nurse provide regarding self care while breastfeeding? A. Birth control measures are unnecessary while breastfeeding B. Soap should be used to cleanse the breasts BID C. Prenatal vitamins should be discontinued D. Additional PO fluids are encouraged
D
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A. A newborn who is 24 hr post-delivery and has not voided. B. A newborn who is 18 hr post-delivery and has acrocyanosis C. A newborn who is 24 hr post-delivery and has not passed meconium D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)
D Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.
A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide? A. "I'll feed him today. Maybe tomorrow you can try it." B. "Oh, this isn't difficult. You'll be fine doing this." C. "You can learn to feed him; I wasn't comfortable the first time I fed a baby either." D. "Feeding an infant can feel a little intimidating at first, but I'll stay and help you."
D (The nurse, while recognizing and acknowledging the client's apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence.)
A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest? A. Apply mineral oil to the nipples between feedings. B. Keep the nipples covered between breastfeeding sessions. C. Increase the length of time between feedings. D. Change the newborn's position on the nipples with each feeding.
D (client should expose sore nipples to air as much as possible and decreasing frequency of feedings does not prevent sore nipples)
At birth, a newborn's assessment reveals the following: - Heart rate 140 - Loud crying - Some flexion of the extremities - Crying when the bulb syringe is introduced into the nares - Pink body with blue extremities The nurse would document the newborn's Apgar score as: A. 5 B. 6 C. 7 D. 8
D - Heart rate 140 (2) - Loud crying (2) - Some flexion of the extremities (1) - Crying when the bulb syringe is introduced into the nares (2) - Pink body with blue extremities (1)
A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make? A. you might want to offer water supplements between feedings. B. this might be related to your baby having 3 stools a day C. it is due to the newborns loss of the influence of the maternal hormones D. the cause might be too short or infrequent feedings
D Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal factors such as breasts not emptying, stress, and fatigue.
Client calls out to the nurses' station reporting that their newborn still won't eat. The client is an LGA male gender assigned at birth neonate born 8 hours ago at 36 weeks gestation. Apgars were 8/8. The pregnancy was complicated by insulin dependent gestational diabetes. Blood glucose since birth have been 41, 46, and most recent 44. Maternal blood type A-, neonatal blood type A+. The neonate is breastfeeding and last ate 4 hours ago. Vital signs: T 97.4, P 142, RR 46. The neonate is sleepy, jittery, and rooting reflex is unable to be elicited. LCTA. Skin is slightly cool to touch, pink with acrocyanosis on the hands and feet. No void or stool since birth. The client is at highest risk for developing: A. cold stress B. kernicterus C. severe hypoglycemia as evidenced by the client's: A. vital signs B. blood glucose levels C. blood type D. neurological assessment
The client is at highest risk for developing: A. cold stress B. kernicterus C. severe hypoglycemia as evidenced by the client's: A. vital signs B. blood glucose levels C. blood type D. neurological assessment