Maternal Newborn CMS PRACTICE SET #7

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?

Cold cabbage leaves. The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?

Place the newborn skin to skin on the mother's chest. Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.

A nurse is providing prenatal teaching to a client who is at 26 weeks of gestation. Which of the following positions should the nurse recommend for the client to increase circulation to the placenta?

Side-lying. In order to increase placental circulation, the nurse should recommend the side-lying position to a client who is pregnant, which avoids the compression of the vena cava. Decreased circulation in the uterus can lead to having a child who is small for gestational age.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect? (Select all that apply.)

Creases over two-thirds of the soles of the feet. Fewer creases over the soles of the feet is an indication of prematurity. Creases over the entire soles of the feet is an indication of postmaturity. Molding of the head. Molding occurs during the birth process as the newborn travels through the birth canal, resulting in compression of the soft bones of the skull. Lanugo on the shoulders. Absence of lanugo is an indication of postmaturity. Abundant lanugo is an indication of prematurity.

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. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new mother moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Palpate the fundus to identify the fetal part. Determine the location of the fetal back. Palpate for the fetal part presenting at the inlet. Identify the attitude of the head. The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is teaching a group of parents about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?

"I will dress my baby in flame-retardant clothing." The parents should dress their newborns in flame-retardant clothing to prevent injury.

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 her teaching?

"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should teach the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

A nurse is developing an educational program for adolescents about nutrition during the third trimester of pregnancy. Which of the following statements should the nurse include in the program?

"Consume three to four servings of dairy each day." Calcium intake is especially important during an adolescent's pregnancy because bone absorption of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume three to four servings of dairy per day to meet their calcium needs.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?

A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.

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? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for delivery.

A nurse is providing discharge teaching to a parent whose newborn has just had a circumcision. Which of the following instructions should the nurse include?

Apply slight pressure with a sterile gauze pad for mild bleeding. The nurse should instruct the client to attempt to stop mild bleeding by applying pressure with sterile gauze. If bleeding continues, the client should notify the provider.

A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?

Attention-focusing. Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.

A nurse is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the nurse include when discussing true labor?

Contractions become stronger with walking. The contractions that occur during true labor become stronger and more regular with a change in activity, such as walking.

A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?

Massage the client's fundus. Uterine hypotonicity and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, causing death to occur. Therefore, the nurse's priority is to massage the client's fundus in order to minimize blood loss.

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.

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 phases of labor?

Transition. The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.

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

Unilateral breast pain. Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider.

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?

Vaginal pressure. The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.

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." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which of the following information should the nurse include?

"Your newborn should appear content after each feeding." The nurse should inform the client that a baby who is sated will appear content after feedings. A baby who continues to show indications of hunger. For example, rooting, sucking on the hands, or crying might not be effectively emptying the breasts during feedings.

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?

"The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should teach the mother to never allow anyone who is not wearing an identification badge to come in contact with her newborn.

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

"This process should have no effect on your sexual performance or adequacy." The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual performance or adequacy. It can actually enhance enjoyment of sex because there is no fear of pregnancy.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?

"You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.

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." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

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

"You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain results.

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50 mL/hr

A nurse is assessing a client who is 12 hr postpartum. The client's fundus is two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?

Assist the client to the bathroom to void. A distended bladder inhibits the uterus from contracting normally and can cause uterine atony. Therefore, the nurse should assist the client to void.

A nurse is performing a vaginal examination for a client who is in active labor and reports back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that the fetus is in the occiput posterior position. Which of the following actions should the nurse take?

Assist the client to the hands and knees position. The nurse should assist the client into the hands and knees position during contractions. This position can help relieve her back pain and it will enable the rotation of the fetus from the posterior to an anterior occiput position.

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority?

Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well- being. Therefore, this is the priority action the nurse should take.

A nurse is assessing a client who is in active labor and notes early decelerations in the FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take?

Continue monitoring the client. Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse should continue to monitor the client.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas

A nurse is caring for a client who is at 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 occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?

Hypertension. The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.

A nurse in a woman'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. The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

Late decelerations. Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

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 in order to assess the point of maximum intensity of the fetal heart?

Left lower quadrant. The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?

Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that he understands his role in the family.

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect?

Petechiae over the head. Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.

A nurse in a provider's office is reviewing the medical record of a client who isin her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?

Pregestational diabetes mellitus. Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

A nurse is planning care for a client who is at 24 weeks of gestation and reports daily mild headaches. Which of the following instructions should the nurse include in the plan of care?

Recommend that the client perform conscious relaxation techniques daily. The nurse should include conscious relaxation techniques in the plan of care as a way to relieve tension and reduce stress, which can help to decrease and eliminate headaches.

A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

The client's room number. Using the client's room number is not an acceptable identifier and places the client at risk for a medication error. Therefore, the charge nurse should intervene.

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

The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.

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

Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?

Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.

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

"I will eat foods that appeal to my taste instead of trying to balance my meals." Clients who have hyperemesis gravidarum should eat to taste to avoid nausea.

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

"I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.

A nurse is caring for a client who has recently experienced a perinatal death. Which of the following statements should the nurse make to the client?

"I'm sad for you." The nurse is offering empathy to the client to facilitate further communication about the perinatal death.

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? (Select all that apply.)

Cholecystitis. A history of gallbladder disease is a contraindication for the use of oral contraceptive . contraindication for the use of oral contraceptives. Hypertension. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches. A history of migraine headaches is a contraindication for the use or oral contraceptives.

A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best nonpharmacological intervention to perform to relieve the client's discomfort?

Counter-pressure. According to evidence-based practice, counter-pressure is the best nonpharmacological technique to use when relieving the client's discomfort from the fetus being in a posterior position because this intervention lifts the fetal head off of the spinal nerve.

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. A client who has ITP has an autoimmune response that results in a decreased platelet count.

A nurse is assessing a client who is at 26 weeks of gestation. Which of the following clinical manifestations should the nurse report to the provider?

Decreased urine output. Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be indications of preeclampsia and should be reported to the provider.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.

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. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is teaching clients in a prenatal class about the importance of taking folic acid during pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities?

Neural tube defect. The nurse should inform the clients that neural tube defects are more common in newborns born to mothers who had inadequate folic acid intake. Food sources of folic acid include fortified cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus.

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

Position the car seat rear-facing in the back seat of the vehicle. The nurse should instruct the parents to position the car seat rear-facing in the back seat of the vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head and weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rear-facing in the backseat until they are 2 years old or reach the height and weight requirements of the car seat manufacturer.

A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?

Respiratory distress. Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a clinical manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

A nurse is assessing a full-term newborn 15 min after birth. Which of the following findings requires intervention by the nurse?

Respiratory rate 18/min. During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this time requires further evaluation and intervention by the nurse.

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. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

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

Substernal chest retractions while sleeping. Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This clinical manifestation requires further assessment and intervention by the nurse.