Maternal Newborn 2016 A
Teaching a pt. who is pregnant about managing N/V. Which of the following instructions should the nurse include in the teaching?
"Eat high-carbohydrate foods." (The nurse should instruct the client to eat high-carbohydrate foods (for example, toast, potatoes, and rice) to decrease nausea and vomiting. The nurse should also instruct the client to avoid spicy, fatty, or fried foods.)
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
"Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen."
A nurse is teaching a pt. who is at 10 wks of gestation about nutrition during pregnancy. Which of the following statements by the pt. indicates an understanding?
"I should take 600 micrograms of folic acid each day." (A client who is pregnant should increase her folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.)
A nurse is teaching a pt. who is in preterm labor about terbutaline. Which of the following statements by the pt. indicates an understanding of the teaching?
"I will have blood tests because my potassium might decrease." (administered submit every 4 hr for no longer than 24 hrs. Hyperglycemia, hypokalemia, and hypotension are all adverse effects.)f
A nurse is teaching a pt. about Rho(D) immune globulin. Which statement by the pt. indicates understanding?
"I will need this medication if I have an amniocentesis" (Rho(D) immune globulin is given following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.)
A nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. Which of the following statements should the nurse make?
"Staff members who take care of your baby will be wearing a photo identification badge." (The nurse should teach the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of her newborn's safety.)
A nurse in a prenatal clinic is caring for a pt. who reports that her menstrual period is 2 wks late. The pt. appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make.
"You can miss your period for several other reasons. Describe your typical menstrual cycle" (Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.)
A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching?
"You can share your room with your baby for the nxt few wks." (Room-sharing is recommended during the first few weeks. This allows the parents to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parents to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.)
A nurse is teaching a pt. who is at 8 wks of gestation about exercise. Which of the following instructions should the nurse include in the teaching?
"You should exercise for 30 mins each day." (The nurse should instruct the client to engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy.)
A nurse is providing discharge teaching to a pt. who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
"You should get a 2-hr oral glucose tolerance test in 6-12 wks." (The nurse should instruct the client to get a 2-hr oral glucose tolerance test 6 to 12 weeks postpartum and every 3 years to screen for type 2 diabetes mellitus.)
Family planning for a pt. with a new prescription for a diaphragm. Which of the following statements should be included?
"You should leave the diaphragm in place for at least 6 hrs after intercourse." (The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.)
A nurse is providing teaching about comfort measures to a pt. who is breastfeeding and is experiencing engorgement. Which of the following nonpharmacological measures should the nurse include in the teaching?
"You should use cold compresses after each feeding." (The nurse should suggest applying cold compresses or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding.)
A pt. who is at 34 wks of gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the following responses should the nurse make?
"You will notice blood-tinged discharge from your vagina." (The nurse should inform the client that a sign of true labor is the bloody show, which is a blood-tinged discharge from the vagina that occurs when the cervix begins to efface and dilate. This is an indication that the client should go to the hospital.)
A nurse is caring for a pt. who is in active labor and has had no cervical change in the last 4 hrs. Which of the following statements should the nurse make?
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." (Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor.)
A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10 mcg/mL. How may mL should the nurse administer? (nearest 10th)
0.5 mL
A nurse in a prenatal clinic is assessing a group of pts. Which of the following pts. should the nurse request the provider see first?
A client who is at 11 wks of gestation and reports abdominal cramping. (When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.)
A nurse on an antepartum unit is caring for 4 pts. Which of the following pts. should the nurse identify as the priority?
A client who is at 34 wks of gestation and reports epigastric pain. (Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.)
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (select all)
A heart rate of 154/min Respiratory rate 58/min Weight 2.6 kg (5 lbs 12 oz) (HR: 110-160, Temp range: 36.5-37.5 or 97.7-99.5, RR: 30-60, length: 45-55cm or 17.7-21.7 in, weight: 2.5-4kg or 5.5lb to 8.8lb)
A nurse is caring for a pt. who is anemic at 32 wks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn. (Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.)
A nurse is caring for a pt who is at 26 wks of gestation and has epilepsy. The nurse enters the room and observes the pt having a seizure. After turning the pt's head to one side, which of the following actions should the nurse take next?
Administer O2 via a nonrebreather mask (When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus.)
A nurse on the postpartum unit is caring for a pt. following a cesarean birth. Which of the following assessments is the nurse's priority.?
Amount of lochia (When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage)
A nurse is planning discharge for a pt. who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for the lactation suppression?
Apply cabbage leaves to the breasts. (Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.)
A nurse is caring for a pt who is in labor and whose fetus is in the right occiput posterior position. The pt. is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?
Apply sacral counter pressure. (The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.)
Assessing a pt. who gave birth vaginally 12 hrs ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Assist the client to empty her bladder. (The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.)
Pt. has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
BUN 25 mg/dL (The nurse should report an elevated BUN to the provider since it can indicate dehydration.)
A nurse is caring for a pt. who is at 36 wks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests?
Biophysical profile (A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with real-time ultrasound.)
A nurse is reviewing the medical record of a pt. who is one day postpartum. The pt. had a vaginal birth with a 4th-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions?
Bisacodyl rectal suppository daily as needed for constipation. (The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection.)
A nurse is caring for a prenatal pt who has parvovirus B19 (5th disease). Which of the following actions should the nurse take?
Schedule an ultrasound examination. (The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops)
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain.
Chin quivering (Behavioral responses to a newborn's pain include facial expressions (for example, chin quivering, grimacing, and furrowing of the brow.HR increases with pain, newborn's pupils typically dilate, respirations are typically rapid and shallow with pain).
A nurse is caring for a pt. becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Determine respiratory function. (The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.)
A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?
Dry the newborn (When using the urgent vs. nonurgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take immediately after delivery is to dry the newborn.)
A nurse in the antepartum clinic is assessing a pt's adaption to pregnancy. The pt. states that she is, "happy one minute and crying the next." The nurse should interpret the pt's statement as indication of which of the following?
Emotional lability (The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many women experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.)
A nurse is teaching a client who is at 35 wks of gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
Headache that is unrelieved by analgesia (A headache that is unrelieved by analgesia may indicate preeclampsia and should be reported to the provider.)
A nurse is reviewing the lab report of a pt. who is 24 hrs postpartum following a vaginal delivery. Which of the following lab results should the nurse identify as an indicator of a postpartum infection?
Erythrocyte sedimentation rate (ESR) 26 mm/hr (The nurse should realize that this value exceeds the expected reference range for a postpartum client and indicates an infection.)
A nurse is performing a routine assessment on a pt. who is at 18 wks of gestation. Which of the following findings should be expected?
FHR 152/min (The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.)
A nurse is assessing a pt who is in labor and notes early decelerations on the fetal monitor. Which of the following findings should the nurse identify as a possible cause of the early decelerations?
Fetal head compression (The nurse should identify fetal head compression as a likely cause of the early decelerations on the fetal monitor. Early decelerations are an expected fetal pattern caused by fetal head compression due to uterine contractions, fundal pressure, and vaginal examinations.)
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (select all)
Flaccid uterus Excessive vaginal bleeding (oxytocin increases the contractility of the uterus.)
A nurse in an antepartal clinic is providing care for a client who is at 26 wks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider?
Fundal height measurement (A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.)
Pt is 35 wks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Appropriate action to take?
Have the client change positions. (Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.)
A nurse is planning care for a pt. who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected. (Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.)
A nurse is assessing a newborn 12 hrs after birth. Which of the following manifestations should the nurse report to the MD?
Jaundice (Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.)
A nurse is caring for a pt who is pregnant and is at the end of her 1st trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT) ?
Just above the symphysis pubis (At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHTs just above the symphysis pubis.)
A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior?
Lays the newborn across her lap and gently sways.
A nurse is caring for a pt. following an amniocentesis at 18 wks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
Leakage of fluid from the vagina. (Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.)
A nurse is caring for a postpartum pt who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Maintain the client on best rest. (The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism.)
A nurse on a postpartum unit is caring for a pt. who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
Massage the client's fundus (The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.)
A nurse is assessing a newborn who was born at 26 wks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil (The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.)
A nurse is caring for a pt. who is at 38 wks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
Perform Leopold maneuvers (The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.)
Reviewing the medical records of a pt. who is postpartum and has preeclampsia. Which lab results should be reported to the MD?
Platelets 50,000/mm3 (A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.)
A nurse is creating a plan of care for a pt. who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?
Protect the client's head and feet from cold air. (Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.)
A staff nurse on an obstetric unit is caring for a pt. who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she has a moral issue withe the pt's decision. Which of the following actions should the nurse manager take?
Reassign the client to another staff nurse (The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. Therefore, the nurse manager should reassign the care of the client to another staff nurse.)
Developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Remove all clothing from the newborn except the diaper. (The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.)
A nurse is calculating a pt's expected date of birth using Naegele's rule. The pt. tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the pt's expected date of birth?
September 3rd (When using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.)
A nurse is assessing a pt. who is at 30 wks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
Swelling of the face (Swelling of the face, sacral area, and hands can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.)
Caring for a pt. and her partner who have experienced a fetal death. Which action should be taken?
Take photos of the newborn to give to the parents. (The nurse should create a memory box that includes mementos of the newborn (for example, photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket.)
A nurse is planning care for a pt who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
Temperature (The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.)
A charge nurse on a L&D unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the 1st step of Leopold maneuvers.
The nurse palpates the pt's abdomen with her palms to determine which fetal part is in the uterine funds. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus
A nurse is caring for a client who is at 36 wks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
To locate a pocket of fluid. (An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.)
A nurse is assesing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Vomiting (Expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. You would also expect tachypnea, hypoglycemia, and low birth weight with fetal exposure to SSRIs).
A nurse is demonstrating to a pt. how to bathe her newborn. In which order should the nurse perform the following actions?
Wipe the newborn's eyes from the inner canthus outward Wash the newborn's neck by lifting the newborn's chin Cleanse the skin around the newborn's umbilical cord stump Wash the newborn's legs and feet Clean the newborn's diaper area (The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.)