Maternal Newborn Practice 2019 A
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? Select all that apply. 1) yellow schlera 2) acrocyanosis 3) posterior fontanel larger than the anterior 4) positive Babinski reflex 5) two umbilical arteries visible
Acrocyanosis Positive Babinski reflex Two umbilical arteries visible is correct
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? 1) administer ASA for pain 2) maintain the client on bed rest 3) massage affected leg every 12 hours 4) apply cold compressed to the affected calf
Maintain the client of bed rest
A nurse is providing teaching about nonpharmological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? 1) cold cabbage leaves 2) purified lanolin cream 3) a snug-fitting support bra 4) breast shells
Cold cabbage leaves
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider? 1) late decelerations 2) moderate variability of the FHR 3) cessation of uterine dilation 4) prolonged active phase of labor
Late Decelerations
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? 1) reports increased urinary output 2) sweating 3) blurred vision 4) shallow respirations
Reports increased urinary output
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? 1) substernal retractions 2) acrocyanosis 3) overlapping suture lines 4) head circumference of 13 in
Substernal Retractions
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? 1) abruptio placenta 2) placenta previa 3) preeclampsia 4) maternal bradycardia
Abruptio placenta
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? 1) nausea 2) urinary output 40 mL/hr 3) respiratory rate 10/min 4) flushing
Respiratory rate 10/min
A nurse is preparing to administer magnesium sulfate 2g/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?
50 ml/hr
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? 1) give the client orange juice 2) elevate the client's legs 3) have the client change positions 4) establish IV access
Have the client change positions
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? 1) HTN 2) hypothermia 3) constipation 4) muscle weakness
Hypertension
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? 1) lays the newborn across her lap and gently sways 2) places the newborn in the crib in a prone position 3) offers the newborn a pacifier dipper in the formula 4) prepares a bottle of formula mixed with rice cereal
Lays the newborn across her lap and gently sways
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test? 1) biophysical profile 2) amniocentesis 3) cordocentesis 4) Kleihauer-Betke test
Biophysicial profile
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? 1) depression 2) polyuria 3) hypotension 4) urticaria
Depression
A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the development of preeclampsia? 1) singleton pregnancy 2) BMI of 20 3) Maternal age 32 years 4) pregestational DM
Pregestational Diabetes Mellitus
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? 1) Verify that the parent's identification band matches the newborn's identification band 2) Scan the newborn's ID band to verify their identity 3) check the newborn's security tag number to ensure it matches the newborn's medical record 4) match the newborn's date and time of birth to the information in the parent's medical record
Verify that the parent's identification band matches the newborn's identification band
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? 1) I should increase my protein to 60 grams each day 2) I should drink 2 liters of water each day 3) I should increase my calories by 300 4) I should take 600 mcg folic acid every day
"I should take 600 micrograms of folic acid every day"
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the following outcomes should the nurse expect? 1) decreased uterine contractions 2) an increase in the client's hemoglobin levels 3) a reduction in respiratory distress in the newborn 4) increased production of antibodies in the newborn
A reduction in respiratory distress in the newborn
A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? 1) hemoglobin 10 g/dL 2) WBC count 10,000 3) Platelets 250,000 4) fasting blood glucose 90
Hemoglobin 10 g/dL
A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? 1) check the client's temp 2) observe for contractions 3) administer Rho-Gam 4) monitor the FHR
Monitor the FHR
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a C-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should be administered?
Naloxone
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 in accepting the new family memeber?
Obtain an gift from the newborn to present to the sibling
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? 1) determine dilation and effacement 2) perform Leopold maneuvers 3) complete a sterile speculum exam 4) prepare a Nitrazine paper test
Perform Leopold Maneuvers
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopoid maneuvers. Which of the following images indicates the first step of Leopoid maneuvers?
Picture of nurse palpating top of belly; where bottom is
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? 1) apply a cool pack for 10 minutes to the heel prior to the puncture 2) request IM analgesic 3) use a manual lance blade to pierce the skin 4) place the newborn skin to skin on the mothers chest
Place the newborn skin to skin on the mothers chest
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? 1) excessive bleeding 2) oligohydramnios 3) premature ROM 4) proteinuria
Premature rupture of membranes
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan? 1) feed the newborn 1 oz of water every 4 hours 2) apply lotion to the newborn's skin three times a day 3) remove all clothing from the newborn except the diaper 4) discontinue therapy if the newborn develops a rash
Remove all clothing form the newborn except the diaper
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? 1) DTR +4 2) fundal height 14 cm 3) urine protein 2+ 4) FHR 152/min
FHR 152/min
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"
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? 1) acrocyanosis 2) transient strabismus 3) jaundice 4) caput succedaneum
Jaundice
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? 1) I won't gain more than 15-20 pounds during my pregnancy 2) I will likely need to use alternative sex positions 3) I'm glad I had a breast reduction years ago, so they will not enlarge 4) I'm glad I have a light complexion, so I don't get stretch marks
"I will likely need to use alternative positions for sexual intercourse".
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? 1) a client who is at 11 weeks of gestation and reports abdominal cramping 2) a client who is at 15 weeks of gestation and reports tingling and numbness in right hand 3) a client who is at 20 weeks of gestation and reports constipation for the past 4 days 4) a client who is at 8 weeks of gestation and reports having 3 bloody noses in the past week
A client who is at 11 weeks of gestation and reports abdominal cramping
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure? 1) monitor the FHR 2) assess uterine activity 3) administer O2 via nonbreather mask 4) start an IV bolus
Administer oxygen via a nonrebreather mask
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? 1) perform Nitrazine testing 2) assess the fluid 3) check cervial dilation 4) begin FHR monitoring
Begin FHR monitoring
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks 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 nurse is performing a vaginal exam on a client who 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? 1) Insert two gloved fingers into the vagina and apply upward pressure to the presenting part 2) wrap the cord tightly with sterile gauze 3) apply O2 at 2L via nasal cannula 4) place the client in the lithotomy position and apply fundal pressure
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse priority? 1) check capillary refill 2) massage the client's fundus 3) insert an indwelling urinary catheter 4) prepare the client for a blood transfusion
Massage the client's fundus
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? 1) monitor the client's BP every hour 2) restrict the total hourly intake to 200 mL 3) monitor the FHR continiously 4) administer protamine sulfate for toxicity
Monitor the FHR continously
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? 1) bruising over the buttocks 2) har nodules on roof of the mouth 3) petechiae over the head 4) bilateral periauricular papillomas
Petechiae over the head
A nurse is creating a plan of care 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? 1) protect the client's head and feet from cold air 2) bathe the client within 12 hour following birth 3) ambulate the client within 24 hours following birth 4) offer the client cold milk with her first meal
Protects the client's head and feet from cold air
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? 1) fundal height 34cm 2) report of decreased fetal movement 3) report of occasional ankle swelling 4) BP 110/80
Reports of decreased fetal movement
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? 1) hypertonia 2) increased feeding 3) hyperthermia 4) respiratory distress
Respiratory distress
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? 1) administer antiviral medication 2) schedule an ultrasound 3) administer flu type b vaccine 4) schedule an indirect Coomb's test
Schedule an ultrasound examination
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? 1) to estimate fetal weight 2) to locate a pocket of fluid 3) to determine multiparity 4) to prescreen for fetal anomalies
To locate the pocket of fluid
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?
Wipe eyes Wash Neck Cleanse skin around umbilical cord stump Wash legs and feet Clean diaper area
A nurse is providing teaching for a client who have birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? 1) my sister will be able to carry my baby from the nurse to my room when she arrives 2) the nurse will match my wrist band to my baby's crib card when they bring him to me 3) the person who comes to take my baby's pictures will be wearing a photo identification badge 4) my baby doesn't need to wear the electronic secuirty bracelet when he's in my room
the person who comes to take my baby's pictures will be wearing a photo identification badge
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? 1) obtain informed consent before getting the specimen 2) collect at least 1 mL of urine for the test 3) ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen 4) premature newborns may have a false-negative test due to immature development of liver enzymes
"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen"
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? 1) "I can administer oxytocin 4 hours after the insertion of the medication" 2) "you will need a full bladder prior to the insertion of the medication" 3) "remain in a side-lying position for 15 minutes after medication is given" 4) "an antacid will be given 20 minutes prior to the insertion of the medication"
"I can administer oxytocin 4 hours after the insertion of the medication"
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include? 1) the test should take 10-15 minutes 2) you will lay supine during the test 3) you should be NPO for 2 hours before the test 4) "You should press the handheld button when you feel your baby move."
"You should press the handheld button when you feel your baby move."
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? 1) erythema toxicum on the face 2) not passed a meconium stool 3) pink-tinged urine 4) axillary temp of 99.9
A newborn who is 18 hr old and has an axillary temperature of 99.9° F
A nurse is caring for a client who 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
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? 1) 2+ DTR 2) proteinuria of 200 mg in a 24-hr specimen 3) polyuria 4) blurred vision
Blurred Vision
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? 1) calcium gluconate 2) hydralazine 3) medroxyprogesterone acetate 4) methylergonovine
Calcium Gluconate
A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect? Select all that apply. 1) heart rate 154/min 2) axillary temperature of 96.8 3) respiratory rate 58/min 4) length 43cm 5) weight 5lb & 12 oz
Heart Rate 154/ min Respiratory rate 58/ min Weight 2,600 g (5lb 12 oz)
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? 1) Kleihauer-Betke test 2) progesterone serum level 3) L/S ratio 4) material alpha-fetoprotein
Kleihauer-Betke test
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? 1) minimal arm recoil 2) popliteal angle of 90 degrees 3) creases over the entire foot sole 4) raised areolas with 3-4mm buds
Minimal arm recoil
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? 1) visual disturbances 2) tingling of the fingers 3) urinary frequency 4) leg cramps
Report of visual disturbances
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Report the client's condition to the local health department
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? 1) lochia serosa 2) vaginal pressure 3) intermittent vaginal pain 4) yellow exudate vaginal drainage
Vaginal pressure
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? 1) blood pressure 136/88 2) insomnia 3) weight gain of 4.8 lbs 4) report of Braxton Hicks contractions
Weight gain of 2.2 kg (4.8 lb)