Maternal Neonatal Nursing

A nurse is administering vitamin K to a neonate following birth. The medication comes in a concentration of 2 mg/mL, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters would the nurse administer? Record your answer using two decimal places

0.25

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note below, which postpartum complication has the client developed? 6/7 1745 Client's 24-hour blood loss is 600 mL. Uterus is soft and relaxed on palpation and client has a full bladder. Assisted client in emptying bladder and notified Dr. G of findings. Vital signs stable at present. See graphic sheet for ongoing assessments and perineal pad weights 1. postpartum hemorrhage 2. puerperal infection 3. urinary tract infection 4. pyelonephritis 5. uterine rupture

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A primigravida client arrives at the labor and birth unit at 39 weeks gestation. After completing the initial assessment, the nurse documents the following 7/27 0700 The client presents to the labor and childbirth unit stating pain radiating from the back to abdomen. Contractions are noted on the fetal monitor varying between every 8-10 minutes. Accelerations with movement and moderate variability noted. The fetal heart rate is 120 bpm. Client verbalizes a 6 on the 0-10 pain scale during contractions. Membranes intact. Cervical dilation 4 cm. HCP notified 1. Provide instructions to remain within 10 minutes of the birthing center and the ambulate 2. Admit the client to the labor and birth unit and prepare for placement of an epidural catheter 3. Instruct the client to rest and tur on the left side 4. Prepare the client for a cesarean section

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The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse below, which action is most appropriate at this time? 06/11 1830 Client's vital signs stable at present. Perineal pad changed for moderate amount of red drainage. Uterus palpated at the level of the umbilicus and to the left side of the abdomen 1. Ask the client to empty her bladder 2. Raise the head of the bed 3. Call the client's primary health care provider for direction 4. Straight catheterize the client for half of her urine volume 5. Notify the charge nurse of the assessment findings

1

A client at 30 weeks' gestation experiences a rupture of membranes with mild contractions eight minutes apart. Which nursing interventions are included on the plan of care to improve newborn outcomes? Select all that apply. 1. Maintain the client on the fetal monitor throughout the labor process 2. Administer a dose of betamethasone per health care provider's order 3. Arrange a neonatologist to be available for the birth 4. Ensure the mother remains nothing by mouth throughout the labor 5. Position the mother in a supine position with the feet elevated 6. Begin an oxytocin drip once the mother reaches 3 cm dilated

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A nurse is caring for a postterm client at 41 weeks of gestation who is about to undergo a biophysical profile to evaluate her fetus's well-being. The client asks, "What will be able to be determined from this test?" The nurse is correct to answer which? Select all that apply. 1. fetal tone 2. fetal breathing 3. femur length 4. amniotic fluid volume 5. biparietal diameter 6. crown-rump length

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The nurse is giving prenatal instructions to a 32-year-old primigravida. Which nutritional instructions would the nurse review? Select all that apply. 1. Caloric intake would be increased by 300 cal/day 2. Protein intake would be increased to more than 30 g/day 3. Vitamin intake would not increase from prepregnancy requirements 4. Folic acid intake would be increased to 800 mg/day 5. Intake of all minerals, especially iron, would be increased 6. Water intake would be doubled

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A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply 1. talks to and coos at her son 2. cuddles her son close to her 3. does not make eye contact with her son 4. requests that the nurse take the baby to the nursery for feedings 5. counts the fingers and toes of her son 6. takes a nap when the baby is also sleeping

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What information would the nurse include when teaching postcircumcision care to the parents of a neonate? Select all that apply 1. The parent must note that the neonate has voided 2. Petroleum jelly or antibiotic ointment would be applied to the glans of the penis with each diaper change 3. The infant can have tub baths while the circumcision heals 4. Any amount of blood noted on the front of the diaper would be reported 5. The circumcision will require care for 2 to 4 days after discharge

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Five days postpartum following an uneventful vaginal birth, a client phones the obstetrician's office stating various symptoms and requesting an appointment. As the nurse is documenting symptoms, which indicate a potential puerperal infection? Select all that apply 1. Temperature of 100.8 F 2. Serosanguineous drainage on the perineal pad 3. Frequent abdominal pain requiring medication 4. Reddened area increasing around episiotomy 5. Slight edema to perineum 6. Ecchymosis in the perineal area

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A mother with a history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below would lead to this nursing judgment? Select all that apply 1. sudden dyspnea 2. chills, fever 3. diaphoresis 4. cough 5. confusion 6. chest pain

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A nurse is evaluating a client who is 34 weeks pregnant for preterm rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply. 1. fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry 2. acidic pH of fluid when tested with nitrazine paper 3. presence of amniotic fluid in the vagina 4. cervical dilation of 6 cm 5. alkaline pH of fluid when tested with nitrazine paper 6. contractions occurring every 5 minutes

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A client at 32 weeks of gestation has mild preeclampsia. She is discharged home with instructions to remain in bed rest. She would also be instructed to call her HCP if she experiences which symptoms? Select all that apply. 1. headache 2. increased urine output 3. blurred vision 4. difficulty sleeping 5. epigastric pain 6. severe N/V

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The nurse is admitting a client with suspected diagnosis of abruptio placentae. When assessing client symptoms, which symptoms require HCP notification of this medical emergency? Select all that apply 1. over vaginal bleeding 2. white creamy vaginal discharge 3. a rigid abdomen 4. gastrointestinal upset 5. increased blood pressure 6. rapid uterine contractions

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A registered nurse is delegating the monitoring of a client who is receiving oxytocin to induce labor to a new graduate nurse. When discussing adverse side effects of oxytocin, which conditions would the graduate nurse notify the registered nurse immediately? Select all that apply 1. a blood pressure of 170/92 2. jaundice in the sclera 3. lab work suggesting dehydration 4. fluid overload with crackles in the lung fields 5. palpable uterine tetany 6. a heart rate of 60 bpm

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A nurse is caring for a client who is 32 weeks pregnant and being monitored in the antepartum unit for pregnancy-induced hypertension. The client suddenly reports continuous abdominal pain and vaginal bleeding. Which nursing interventions are priorities? Select all that apply. 1. evaluate maternal vital signs 2. prepare for vaginal birth 3. reassure the client that she will be able to continue the pregnancy 4. auscultate fetal heart tones 5. monitor the amount of vaginal bleeding 6. monitor intake and output

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A client is being admitted to the labor and birth unit. Her GTPAL classification is 5-2-1-1-2. When providing shift handoff, which information would the nurse include? Select all that apply. 1. The client has had four previous pregnancies 2. The client has had five previous pregnancies 3. The client has had one full-term child, one abortion, and one premature child 4. The client has had two full-term children, one premature child, and one abortion 5. The client has three living children following five pregnancies 6. The client has two living children and is pregnant again

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A nurse is evaluating the return demonstration of cord care by the mother of a neonate. Which actions would the nurse encourage the mother to perform? Select all that apply 1. placing the diaper below the cord 2. tugging gently on the cord as it begins to dry 3. applying antibiotic ointment to the cord twice daily 4. sponge bathing the infant cord until the cord falls off 5. cleaning the length of the cord with alcohol several times daily 6. washing the cord with mild soap and water

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A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period? 5/24 1715 Mother verbalizing labor and delivery experience. Doesn't appear confident about holding baby or changing diapers. Asking appropriate questions 1. letting go 2. taking in 3. holding out 4. taking hold

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The obstetric nurse is performing a non-stress test on a 30-week primigravida client sent from a HCP's office. The client reports a decrease in fetal movement over the past 24 hours. The nurse documents the following nursing note 7/27 1100 Client placed on fetal monitor. No fetal movement or reactivity noted over 20 minutes on monitor. No fetal heart rate heard. Client repositioned with no change. HCP notified Which nursing statement is appropriate at this time? 1. Let's have you change your position and lie of you left side 2. I will check with the HCP to see if further tests are needed 3. I bet you are excited about the baby 4. Have you done anything different today?

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During her first prenatal visit, a client asks a nurse what physiological changes she can expect during pregnancy. The nurse begins the discussion with the presumptive changes of pregnancy. Put the following presumptive changes in ascending chronological order according to when they occur. All options must be used. 1. frequent urination 2. breast changes 3. quickening 4. appearance of linea nigra, melasma, and striae gravidarum 5. uterine enlargement in which the uterus can be palpated over the symphysis pubis

2 1 5 3 4 Presumptive changes are subjective and can be caused by other medical conditions

During physical assessment of a client who gave birth 3 hours ago, a nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which nursing actions would be appropriate? Select all that apply 1. Begin an intravenous infusion of lactated Ringer's solution 2. Assess the client's vital signs 3. Palpate the client's fundus 4. Place the client in high Fowler's position 5. Place client on bed rest

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A nurse is caring for a client with history of a warm, reddened, painful area in the breast diagnosed as mastitis as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding throughout treatment. Which instructions would the nurse include to prevent a recurrence of this condition? Select all that apply 1. Wash the nipples with soap and water 2. Change the breast pads frequently 3. Expose the nipples to air for part of each day 4. Wash hands before handling the breast and breast-feeding 5. Make sure that the baby grasps the nipple only 6. Release the baby's grasp on the nipple before removing the baby from the breast

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A client who is 29 weeks pregnant comes to the labor and birth unit. She states that she is having contraction every 8 minutes. The client is also 3 cm dilated. Which can the nurse expect to administer? Select all that apply. 1. folic acid 2. a beta-2 agonist 3. betamethasone 4. Rho(D) immune globulin (RhoGAM) 5. intravenous fluids 6. nalbuphine

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A nurse is caring for a client who is in the third stage of labor. Which characteristic behaviors does the nurse anticipate at this stage? Select all that apply 1. The client is excited about the process 2. The client is focused on the neonate's condition 3. The client is exhausted from continued pushing 4. The client states she has discomfort from uterine contractions 5. The client is apprehensive about the process 6. The client is feeling embarrassed as she has an urge to defecate

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A postpartum client is experiencing thoughts and behaviors common to the taking-hold phase. Which items are characteristic of this phase? Select all that apply 1. prefers having the nurse care for her 2. holds new child and breast-feeds without prompting 3. rests to regain physical strength and calm her swirling thoughts 4. expresses a strong interest in taking care of her child 5. gives up fantasized image of her child and accepts the real one

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A nurse is preparing to teach a client about fetal growth and development during the first 3 months of pregnancy. The nurse is assembling teaching aids by milestones. In ascending order (month 1, month 2, month 3, months 4 to 9), how would the nurse arrange the aids? All options must be used 1. Teeth and bones begin to appear, the kidneys start to function, and, at the end of the month, gender is distinguishable 2. The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the CV system begins to function 3. Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb 4. The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present

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The nurse is assigned to a client who experiences a syncopal episode on her first ambulation after birth. Which nursing actions will the nurse delegate to the licensed practical/vocational nurse. Select all that apply 1. Obtain orthostatic blood pressure 2. Assist the nurse with ambulating the client back to bed 3. Monitor hemoglobin and hematocrit level 4. Assess pain level on a 0 to 10 pain scale 5. Obtain a cool compress for the head 6. Assist with ambulation on the next trip to the bathroom

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A postpartum client has been ordered 500 mg of ampicillin oral suspension. The label reads ampicillin 125 mg/ 5 mL. How many milliliters would the client receive? Record your answer using a whole number

20

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes below, which rationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy? 5/12 1430 Client admitted to short-term procedure unit for testing. States "I'm feeling a little faint." Skin slightly diaphoretic to touch. Client assisted to left side. VS stable. States "I'm feeling better now" 1. to facilitate digestion 2. to facilitate bladder emptying 3. to prevent compression of the vena cava 4. to prevent development of fetal anomalies

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At 5 minutes of age, a neonate is pink with acrocyanosis; has flexed knees, clenched fists, a whimpering cry, and a heart rate of 128 bpm; and withdraws the foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate? 1. 5 2. 7 3. 8 4. 10

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When teaching an antepartum client about the passage of the fetus through the birth canal during labor, the nurse describes the cardinal mechanisms of labor. Using a teaching pelvis and fetus, the nurse demonstrates which sequence during birth? Place these events in the proper sequence. All the options must be used. 1. flexion 2. external rotation 3. descent 4. expulsion 5. internal rotation 6. extension

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A nurse is caring for a client who is anxious to know her baby's due date. The nurse instructs the client on how to determine the baby's due date according to Nagele's rule. The client is correct to state which when discussing the use of the rule? Select all that apply 1. I need to know the date of intercourse when fertilization may have occurred 2. I will calculate 9 months from my last menstrual period 3. Nagele's rule provides a good approximation of the due date 4. I will add 7 days to the first day of my last menstrual period and count back 3 months 5. Nagele's rule may be used in conjunction with other assessment findings

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The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which three neonates are the best client care assignment for the pediatric nurse? Select all that apply 1. an 18-hour, postterm, breast-fed neonate with jaundice 2. a 2-day-old who has not passed a meconium stool 3. a recent admission with Apgar score of 8 and 10 4. a 1-day-old with caput succedaneum 5. a 4-hour-old with a bluish appearance to the hands and feet 6. a 1-day-old with a cleft palate and cleft lip

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A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply 1. The neonate grasps the nurse's finger when put in the palm of the neonate's hand 2. The neonate does stepping movements when held upright with the sole of the foot touching a surface 3. The neonate's toes do not curl downward when the soles of the feet are touched 4. The neonate does not respond when the nurse claps hands 5. The neonate turns toward the nurse's finger when touching the cheek 6. The neonate displays weak, ineffective sucking

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A woman at 15 weeks of gestation comes to the clinic for an amniocentesis. If an abnormal result is found, which characteristics or problems could be identified? Select all that apply. 1. fetal lung maturity 2. gestational diabetes 3. chromosomal defects 4. neural tube defects 5. polyhydramnios 6. sex of the fetus

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A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which statements accurately characterize this disorder? Select all that apply 1. Symptoms appear at the 6-month screening 2. The disorder is common in postpartum women 3. Symptoms include delusions and hallucinations 4. Suicide and infanticide are uncommon in this disorder 5. The disorder rarely occurs without a psychiatric history

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A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note. Which term best identifies the discharge? 3/30 1645 Perineal pad changed two times this shift for moderate amount of red discharge 1. lochia alba 2. lochia 3. lochia serosa 4. lochia rubra

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During a prenatal visit, a health care provider decides to admit a client to the hospital. Based on the nurse's admission note below, which complication of pregnancy would the health care provider suspect? 2/2 1100 30-year-old female admitted with N/V. Client is 16 weeks pregnant and reports of thirst and vertigo. BP 120/70 mm Hg, RR 20, P 104, Temp 100. Client has had nothing to eat or drink for 24 hours 1. iron deficiency anemia 2. placenta previa 3. pregnancy-induced hypertension 4. hyperemesis gravidarum

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A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contractions from the beginning of contraction to its conclusion. All options must be used 1. acme 2. relaxation 3. decrement 4. increment

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A nurse is providing care to a neonate. Place the following steps in the order that the nurse would implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used 1. Close and manipulate the eyelids to spread the medication over the eye 2. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment 3. Repeat the procedure for the other eye 4. Wash hands and put on gloves 5. Instill the ointment in the lower conjunctival sac 6. Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb

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The nurse is caring for a client in labor. Which assessment findings would prompt the nurse to notify the health care provider? Select all that apply. 1. The client is moaning in pain during contractions 2. The fetal heart rate baseline is between 140 and 150 bpm 3. The client is anxious and requests that someone help her 4. The client's membranes rupture, and the amniotic fluid is green 5. Late decelerations are noted on the external fetal monitor strip 6. Blood-tinged mucus is noted upon internal examination

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The nurse is performing an assessment of a client progressing through labor. Place the following findings in the order in which they occur. All options must be used 1. Uncontrollable urge to push 2. Cervical dilation of 7 cm 3. 100% cervical effacement 4. Strong Braxton Hicks contractions 5. Mild contractions lasting 20-40 seconds

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The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. Order the sequence of events for performing this procedure. All options must be used 1. Rotate the upper hand to massage the uterus until firm 2. Place the client in supine position 3. Gently press the fundus between the hands using slight downward pressure 4. Place one hand around the top of the fundus 5. Ask the client to void 6. Place one hand on the abdomen just above the symphysis pubis

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A client is at risk for seizures because of pregnancy-induced hypertension. The health care provider orders 4g magnesium sulfate in 250 mL D5W to be infused at 1g/hour following a loading dose. What is the flow rate in milliliters per hour? Round your answer to the nearest whole number

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