Maternity PREP-U Exam #2

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns."

The prenatal health nurse is conducting an educational session focusing on alcohol use during pregnancy. The nurse feels the session was a success when a participant makes which statement?

"Alcohol use could cause my baby to be intellectually disabled."

An infant born 10 minutes prior was brought into the nursery for an examination. The nurse notices the infant's lip and palate are malformed. The parent comes up to door and asks if the infant seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings."

The nurse gave a presentation about intimate partner violence (IPV) to a local community group. The nurse determines more teaching is needed when a member makes which statement?

"For the victim's safety, the victim has to learn to be careful to not set off the abuser."

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?"

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?

"I can't wait for these stretch marks to disappear after I give birth."

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate the gums."

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment?

"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months."

The nurse is caring for a client who has been a victim of intimate partner violence (IPV) for a few years. The client states, "My partner has been so sweet to me the last few days by telling me how special I am and bringing me flowers. I believe my partner is sorry and will not do this again." How will the nurse respond?

"It may seem better now, but over time, IPV typically becomes accelerated and more dangerous."

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?

"It takes about 3 days after birth for milk to begin forming."

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

"The bladder will be covered in a sterile plastic bag to keep it moist."

The nurse suspects a pregnant client is a victim of intimate partner violence (IPV). When the nurse asks the client if her partner abuses her, the client responds, "Oh no, my partner does not hit me." Which response by the nurse is most appropriate?

"There are many types of intimate partner violence beyond physical abuse."

A client states "My spouse loves me. My spouse did not mean to hit me. My spouse felt so bad, I received flowers to show me how sorry my spouse was for hitting me. I know this will not happen again." How will the nurse respond?

"This is a common action of abusers. It does not mean you will not be hit again."

The newborn weighing 6 lb 6 oz (2856 g) now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?

"This is a normal response."

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset?

"We'll hold off on feeding him for a while because he might be too full."

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

- Avoid coming to work when ill. - Use sterile gloves for an invasive procedure. - Initiate universal precautions when caring for the infant.

A client is experiencing postpartum hemorrhage shortly after the birth of the infant. Which nursing intervention(s) would be appropriate for this client? Select all that apply.

- Encourage the client to breastfeed the infant, if she is breastfeeding. - Begin uterine massage with both hands on the fundus of the uterus. - Turn the client on the side and inspect the area under the buttocks for blood. - Encourage increased fluid intake. - Monitor vital signs every 15 minutes.

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?

108 beats/minute

A neonatal nurse admits a preterm infant with the diagnosis of respiratory distress syndrome and reviews the maternal labor and birth record. Which factors in the record would the nurse correlate with this diagnosis? Select all that apply.

32 weeks' gestation cesarean birth male gender newborn asphyxia maternal diabetes

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?

37.0° C (98.6° F)

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

45 mg/100 ml whole blood

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?

Apply ice.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus.

A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?

BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take?

Document the data.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein pearls.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours.

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?

Gently stroke the newborn's cheek.

The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant?

Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?

Identify the newborn.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client?

No action is need; this is normal.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breastfeeding.

A pregnant woman comes to the clinic with a head injury. She tells the nurse that her partner came home drunk and she made him angry by not having dinner ready. He lashed out, she got in the way, and her head hit the corner on the table. What action should the nurse take in this situation?

Provide the client with contact information for a 24-hour shelter and social worker on discharge.

Which nursing action is required when caring for the post-term infant?

Serial blood glucose levels

A new mother is holding her infant after a feeding. Which behavior by the mother would be concerning to the nurse related to malattachment?

She refers to the infant as "it" instead of saying the infant's name.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn?

Toes fan out when sole of foot is stroked.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues?

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding

The nurse is caring for a client who is a victim of sexual violence. How can the nurse best support the necessary grieving process?

actively listening to the client as he or she talks about the experience

What action by the nurse provides the neonate with sensory stimulation of a human face?

assisting the mother to position the infant in an en face position

Which measurement best describes postpartum hemorrhage?

blood loss of 1,000 ml, occurring at least 24 hours after birth

A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

cephalohematoma

A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor?

congenital dermal melanocytosis (slate gray nevi)

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

during the first 24 hours after birth owing to dehydration from exertion

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.

encouraging kangaroo care during procedures removing tape gently from the skin

A nurse is conducting a program for a community group about violence and abuse. As part of the program, the nurse describes the characteristics of the typical abuser. Which characteristics would the nurse include? Select all that apply.

feelings of insecurity aggression to express inadequacies violence as a means of control antisocial behaviors

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?

fundus two fingerbreadths below umbilicus and firm

The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus?

grow to an unusually large size

The infant is born with copious secretions in the mouth and nose. When using a bulb syringe to remove secretions, the nurse might observe what response from the infant?

heart rate of 88 beats per minute

A young female immigrant has come to the clinic for medical care. On examination, the nurse discovers she underwent female genital cutting as a young girl. The nurse recognizes this practice is primarily based on:

her culture.

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article?

higher oxygen content of the circulating blood

The nurse is reviewing the medical record of a client at 13 weeks' gestation. Which finding most concerns the nurse?

history of intimate partner violence (IPV)

The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?

hypoglycemia

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

inability of infant to empty breasts

A nurse is providing discharge instructions to a postpartum client about possible complications after returning home. For which finding will the client contact the health care provider?

increasing amount and darkening of the color of lochia

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing

While caring for a neonate born of a mother with diabetes, the nurse should monitor the neonate for which complication?

macrosomia

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as:

moderate.

The nurse should carefully monitor which neonate for hyperbilirubinemia?

neonate with ABO incompatibility

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately?

oral temperature 100.8° F (38.2° C)

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l).

poor feeding

When a pregnant client is victim of intimate partner violence during pregnancy, what complication is likely to occur after birth due to the abuse?

postpartum depression

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

postpartum depression.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact?

quiet, alert state

When caring for a neonate receiving phototherapy, the nurse should remember to:

reposition the neonate frequently.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg

The nurse is assisting with the assessment of a newborn. What assessment finding indicates that the nurse needs to monitor the newborn's respiratory status further?

weak cry

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth