Maternal Newborn B

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone (increase fetal lung maturity). Which of the following statements should the nurse make about the indication for medication administration?

" This medication stimulates fetal lung maturity" WHY? Know what Betamethasone is and what it is used for. FETAL LUNG MATURITY

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

" I will have blood tests because my potassium might decrease" WHY? An adverse effect of terbutaline is HYPOKALEMIA

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Massage the client's fundus WHY? The risk for a client is hemorrhage therefore, you have to massage the fundus.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

Biophysical Profile (BPP) WHY? Because a biophysical profile encompasses a non-stress test and an ultrasound to be done to give a full overview of the well-being of the fetus.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

Decreased platelet count WHY? ITP is an autoimmune response that decreases the platelet count.

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?

Flaccid Uterus Excessive vaginal bleeding

A nurse is caring for a client who has preeclampsia and is receiving continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

Have calcium gluconate readily available WHY? Because if the client suffers from magnesium sulfate toxicity , calcium gluconate will be the antidote to reverse it.

A nurse is caring for a client who is pregnant and is at the end of her first 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

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

Oligohydramnios WHY? Oligohydramnios is a lack of amniotic fluid surrounding the baby. FHR is needed to assess the well-being of the baby.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take?

Initiate continuous external fetal monitoring

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?

Stop suctioning when the newborn's cry sounds clear

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature WHY? Temperature is indicative of infection

A nurse is reviewing laboratory results of a newborn who is 4hr old. Which of the following findings should the nurse report to the provider?

Bilirubin 9 mg/dL

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

" A blood glucose of 130-140 is considered a positive screening result" WHY? This is considered positive and therefore the client will need to undergo a 3hr glucose test to confirm to see if she has developed GESTATIONAL DIABETES MELLITUS

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

"I will need this medication if have an amniocentesis"

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, " What effects will this procedure have on my sex life?" Which of the following responses should the nurse make?

"This procedure should have no effect on your sexual performance or adequacy"

A nurse is preparing to perform Leopold Manuevers. Identify the sequence:

1. Palpate the fundus to identify the fetal part ( usually with both hands at the top of the fundus on each side of the belly) 2. Determine the fetal back (using one hand to press against the belly and the other hand to stabilize the side where the hands and feet are felt) 3. Palpate for the fetal part presenting at the inlet (above the pelvic region) 4. Identify the attitude of the head

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. Order states, " Admin azithromycin 1g orally now". Available is 250mg tablets. How many tablets should the nurse give?

4 tablets WHY? You first have to make sure that the two conversion are alike (mg to mg) 1g = 1000mg Thus 1000mg divide/ by 250mg = 4

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives?

A. Cholecystitis B. Hypertension C. Migraine headaches

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions?

Administer terbutaline WHY? Terbutaline is used to stop contractions because the fetal lungs are not mature.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior (ROP). The client is dilated to 8cm and reports back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure WHY? Sacral counterpressure with a tennis ball may be used for client's in active labor. * The best position for the fetus to be in are ROA & LOA*

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpated her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty her bladder WHY? Because the client's uterus was palpated to the right thats a deviation from midline. Therefore, any deviation of the uterus can indicate a need for the client to void.

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to provider?

Blood glucose of 30 mg/dL WHY? This indicates that the blood glucose is too low for the newborn = HYPOGLYCEMIA

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 WHY? Chin quivering is indicative that the child is in pain

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia (excessive amounts of bilirubin in the blood). Which of the following actions should the nurse take?

Cover the newborn's eyes while under phototherapy light WHY? You always want to cover the newborn's eyes because the light used, could have damaging effects on the eyes. (Mainly a damage to the retina and cornea)

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

Demonstrate to the client how to perform a newborn bath

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Determine the respiratory function. WHY? This is important because this can indicate that the client may have stopped breathing and could need resuscitative measures performed. " ABCs"

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, " happy one minute and crying the next," The nurse should interpret the client's statement as an indication of which of the following?

Emotional lability

A nurse is caring for a client who is 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Explain to the client this is an expected outcome WHY? These hyperpigmented areas are known as cholasmas or melasmas (if they are brownish). This is caused by the increase in melanotropin during pregnancy

A nurse is teaching a client who is at 35 weeks of gestation about 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 WHY? This is indicative of preeclampsia

A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?

Hemoglobin 10 g/dL WHY? This result is below the range of 11 g/dL. Low levels of hemoglobin can result in anemia.

A nurse is planning care for a client who is to undergo a non stress 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 WHY? This is the purpose of a non-stress test. The mother is supposed to state when she detects fetal movement and then this is confirmed by a fetal heart monitor (reaction of the fetal movement)

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?

Iron

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

Jitteriness WHY? Jitteriness is indicative of hypoglycemia

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina WHY? Because this leakage of fluid can indicate premature a rupture of the amniotic sac

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?

Left lower quadrant

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.

A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta?

Neural tube defect with a bluish dimple just about the buttocks

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?

Place the retainer clip at the level of the newborn's armpit WHY? This allows a snug fit for the newborn in a car seat.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider?

SOB WHY? This can indicate pulmonary embolus or MI

A nurse is calculating a client's expected date of delivery (EDD) using the Nagele's rule. The client tells the nurse that her last menstrual cycle started on Nov 27th. Which of the following dates is the client's expected date of birth?

September 3rd WHY? Nagele's rule: LMP - 3months + 7 days and a year. Nov 27th - 3 months = August 27th August 27th + 7 days= Sept 3rd

A nurse is assessing a newborn who is 12 hrs old. Which of the following manifestations requires intervention by the nurse?

Substernal chest retractions while sleeping WHY? Substernal chest retractions are indicative the newborn is having respiratory distress/difficulty

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face WHY? Swelling of the face is indicative of gestational hypertension

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following stages of labor?

Transition WHY? Transition stage of labor is characterized by strong to severely strong contractions, frequency is 2 to 3 mins, with a duration of 40-90 seconds. The dilation is complete or from "8 to complete dilation ready to give birth".

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider?

Unilateral breast pain WHY? This is indicative of mastitis and should be reported to the provider

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Verify the newborn's identification. WHY? As a safety/risk reduction. You want to make sure you have the right newborn and performing the right procedures.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

" I will continue taking my insulin if I experience nausea and vomiting" WHY? Think of "the Sick Day Rule" for diabetes management. No matter what unless contraindicated the client should take their insulin to prevent hypoglycemic/hyperglycemic attacks

A nurse is providing dietary teaching to a client who has hyperemesis gravid arum. Which of the following statements by the client indicates an understanding of the teaching?

" I will eat foods that taste good instead of balancing my meals" WHY? Because the mother is nauseous you want her to eat foods that appealing to her and does not cause any nausea.

A nurse is teaching a postpartum client about the steps the nurses will take to promote security and safety of the client's 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" WHY? To ensure the safety of the newborn.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client 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 menstrual cycle." WHY? Because there is not a definitive sign that the client is pregnant. Missing your period can happen for various of reasons. So we want to start out by knowing her cycle ( to determine if it is normal or abnormal)

A nurse is teaching a new parent 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 next few weeks" WHY? This allows for the parent to be readily available to the newborn and identify newborn cues.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

" You should leave the diaphragm in place for at least 6 hrs after intercourse" WHY? Leaving a diaphragm in place after intercourse provides protection against pregnancy.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

" You should take the medication within 72 hours following unprotected sexual intercourse" WHY? Emergency Contraception is needed within 72 hours to prevent unwanted pregnancy.

A nurse is teaching a client who is at 36 weeks of gestation and has prescription for a nonstress test (counting fetal movements). Which of the following statements should the nurse include in the teaching?

" You will be offered orange juice to drink during the test"

A nurse is caring for a client who is in active labor (4-7cm dilated with moderate to severe contractions, frequency of 3-5 mins lasting 40-80 seconds) and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?

" Your provider will insert a intrauterine pressure catheter to monitor the strength of your contractions" WHY? To measure the strength of the mother's contractions and to see if she may need medication to help her dilate

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

A client who is at 34 weeks of gestation and reports epigastric pain WHY? Because epigastric pain is indicative of gestational hypertension/ preeclampsia and hepatic involvement which is urgent

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for LACTATION SUPPRESSION?

Apply cabbage leaves WHY? Applying cabbage leaves or cold decreases stimulation to the breast reducing the production of milk and pain.

A nurse is performing a vaginal examination on a client is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?

Apply internal upward pressure to the presenting part using two gloved fingers WHY? Because this indicates that the vaginal wall is compressing on the umbilical cord thus, can decrease oxygen to the fetus. Therefore, with two sterile gloved fingers, you hold up the vaginal wall of the cord and CALL FOR HELP

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Platelets 50,000/mm^3

A nurse is assessing the newborn of a client who took a SSRI during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Vomiting WHY? SSRIs can induce nausea/vomiting/tremors/diarrhea