Maternal Newborn Practice 2020A

A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching?

"I can use water-soluble lubricant when my partner wears a latex condom." **Water-soluble lubricants should be used with male latex condoms, because the use of any other lubricant can compromise the integrity of the condom.

A nurse is reinforcing home care safety with the guardian of a newborn prior to discharge. Which of the following statements by the guardian indicates understanding of the teaching?

"I should place my baby's crib away from windows." **The guardian should place the newborn's crib away from windows to prevent drafts or entanglement in blinds or drapery.

A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will apply cold cabbage leaves to my breasts throughout the day." **Frequent application of cold cabbage leaves to the breasts can prevent engorgement during lactation suppression for a client who is bottle-feeding her newborn. The client should also apply ice packs or cold compresses to her breasts, take mild analgesics, and wear a well-fitting and supportive bra.

A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching?

"I will ask the nurse to take my baby back to the nursery if i need to leave my room." **The nurse should instruct the parent not to leave the newborn unattended. If the parent needs to leave the room, the parent should call the nurse to transport the newborn back to the nursery.

A nurse is reinforcing about car seat safety with the parent of a newborn. Which of the following client statements indicated an understanding of the teaching?

"If my baby rides in a car with no back seat, the passenger air bag must be turned off" **The nurse should reinforce to the parent that in the event that a newborn cannot ride in the rear seat, the parent must disable the front passenger air bag to prevent potential injuries caused by air bag deployment.

A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughters room. Which of the following responses should the nurse make?

"Let me wash my hands and then ill take the baby to his mother." **Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns.

A client requests information about the use of a diaphragm for birth control. Which of the following statements should the nurse make?

"You will need to replace your diaphragm every 2 years." **The client should replace the diaphragm every 2 years.

A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate.

1/2 cup dried peas **Clients who are pregnant should consume 400 mcg of folate per day. One-half cup of dried green split peas provides 127 mcg of folate and is the best of these sources of folate for the nurse to recommend.

A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider?

2+ urinary protein **The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the nurse should report this finding to the provider.

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?

A client who is at 37 weeks of gestation and reports a persistent headache. **When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The nurse should identify that a persistent headache is a manifestation of preeclampsia and recommend that the provider see this client first.

A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider?

Apical heart rate of 90/min while crying **The nurse should identify that an apical heart rate of 90/min while crying is below the expected reference range of 110 to 160/min for a newborn. A heart rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn.

A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider.

Blood glucose 28 mg/dL **The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 30 to 60 mg/dL for a newborn. Therefore, the nurse should report this finding to the provider.

A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider?

Blurred vision **The nurse should report blurred vision to the provider as it is an indication that the client might have preeclampsia.

A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication?

Cessation of uterine contractions. **Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle of the uterus.

A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first?

Check the newborn's glucose level. **The first action the nurse should take using the nursing process is to collect data from the client; therefore, the first action the nurse should take is to check the newborn's blood glucose level.

A nurse is reinforcing teaching with a client who is at 20 weeks gestation and reports having constipation. Which of the following information should the nurse include?

Consume 28g of fiber per day. **Consuming 28 g of fiber per day will help relieve constipation.

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and has gestational diabetes mellitus. Which of the following information should the nurse include in the teaching?

Consume at least 2,000 cal/day. **A client who has gestational diabetes should consume at least 2,000 kcal/day which is about 35 cal/kg/day. This will ensure adequate glucose intake and prevent hypoglycemia.

A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include?

Consume small meals frequently each day. **The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this increases nausea.

A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity?

Decreased respiratory rate Decreased level of consciousness Double vision **Respiratory depression is a manifestation of magnesium sulfate toxicity. A decreased level of consciousness is a manifestation of magnesium sulfate toxicity. Double vision is a manifestation of magnesium sulfate toxicity.

A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 hr following birth?

Diuresis Discharge of clear, yellow fluid from the breasts Lower abdominal cramping

A nurse is reinforcing reaching with a client who has asked about continuing routine exercise during pregnancy. Which of the following responses should the nurse take?

Drink plenty of water after exercising. **The client should drink plenty of water during and after exercising to decrease the risk of dehydration from diaphoresis.

A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy?

Epigastric pains **The nurse should identify epigastric pain as a potential complication of pregnancy. Epigastric pain is a manifestation of preeclampsia.

A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take?

Explain to the client that they will receive the hepatitis B immune globulin immediately **The nurse should explain to the client the need to receive the hepatitis immune globulin to decrease the risk of transmission to the fetus. The nurse should also instruct the client that all sexual partners and members of the client's household should see their providers to begin prophylactic treatment.

A nurse is collecting data from a client who is in the second trimester of pregnancy. Which of the following findings should the nurse report to the provider?

Frequent uterine contractions. **The nurse should report frequent uterine contractions during the second trimester to the provider because these contractions can cause the cervix to open early and subject the client to preterm labor.

A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2cm above the umbilicus with deviation to the right. Which of the following actions is the nurses priority?

Help the client ambulate to the toilet. **The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to assist the client to urinate and completely empty the bladder, which will allow the uterus to contract.

A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?

Hematocrit 30% The nurse should identify that a hematocrit of 30% is below the expected reference range of greater than 33% for a client who is pregnant. A low Hct is an indication of anemia. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication.

Hypertension **Methylergonovine is an oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage. It can cause nausea, vomiting, cramping, headache, and dizziness. The nurse should report changes in blood pressure to the provider because methylergonovine can cause both hypertension and hypotension.

A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension with a client who is at 16 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching?

I will lie on my left side with my head elevated on a pillow. **The nurse should instruct the client to avoid lying supine during pregnancy to prevent supine hypotension. The uterus compresses the inferior vena cava in the supine position, which decreases blood pressure and causes dizziness and fainting. Lying on the left side prevents compression of the vena cava and subsequent hypotension.

A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take?

Insert an indwelling urinary catheter. **The nurse should insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria.

A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include?

Instruct the client to apply warm compresses to the affected breast. **The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth.

A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse identify as an indication that the client has hyperemesis gravidarum?

Ketonuria The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat secondary to malnutrition or starvation.

A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse expect the provider to prescribe?

Methylergonovine **Methylergonovine is used to treat postpartum hemorrhage. Methylergonovine is an oxytocic medication that causes contraction of the smooth muscle of the uterus, which assists in decreasing the lochia. This medication should not be administered to clients who have preeclampsia or hypertension.

A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete?

Neonatal Abstinence Scoring System **This newborn is exhibiting manifestations of opioid withdrawal and should be screened using the Neonatal Abstinence Scoring System. Some additional manifestations of withdrawal include restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex.

A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions should the nurse take?

Place an opaque mask over the newborn's eyes. **The nurse should place an opaque mask over the newborn's eyes during phototherapy to prevent damage to the retinas. The nurse should remove the mask for feedings.

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

Platelet count 120,000/mm3 **The nurse should identify that a platelet count of 120,000/mm3 is below the expected reference range of 150,000 to 300,000/mm3 for a newborn. Therefore, the nurse should report this finding to the provider.

A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include?

Position the bottle at a 45 degree angle during feedings. **The nurse should reinforce with the parents to position the bottle at a 45° angle during feedings to allow the newborn to have more control during feedings and prevent the swallowing of air.

A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in newborns with a group of clients who are pregnant. Which of the following risk factors should the nurse include?

Prematurity **A newborn who is premature has inadequate surfactant production, which can lead to RDS.

A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following?

Prevent certain kinds of birth defects. **The nurse should inform the client that adequate folic acid intake prior to and early during pregnancy is necessary to help prevent neural tube defects.

A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse?

Prolonged deceleration of FHR. **The nurse should report a prolonged deceleration of the FHR to the charge nurse because it can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse. The charge nurse should notify the provider about this change in FHR pattern.

A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first?

Provide fundal massage for the client. **The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease bleeding.

A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome?

Reactive nonstress test **The nurse should identify that a reactive nonstress test indicates fetal well-being and is a desirable outcome.

A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routines of administration should the nurse plan to use?

Subcutaneous **Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 hr.

A nurse i assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider?

Tachypnea Nasal flaring Retractions Expiratory grunting **Tachypnea is a respiratory rate greater than 60/min and is a finding associated with respiratory distress in the newborn. Nasal flaring is a finding associated with respiratory distress in the newborn. Retractions are a finding associated with respiratory distress in the newborn. Expiratory grunting is a finding associated with respiratory distress in the newborn.

A nurse is observing a client bathe her 1-day old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe the newborn?

The client washes the newborn's hair before unwrapping them. **Keeping the newborn wrapped while washing their hair helps prevent heat loss.

A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy. Which of the following laboratory values should the nurse recognize as an indication that the therapy has been effective?

Total bilirubin 5 mg/dL **The nurse should identify that phototherapy is used to treat newborns who have hyperbilirubinemia. Therefore, the nurse should monitor the newborn's bilirubin level before, during, and after phototherapy. A total bilirubin of 5 mg/dL is within the expected reference range of 1 to 12 mg/dL, which indicates the phototherapy has been effective.

A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect?

Urine output of 3,000 mL in 24 hr. **The nurse should expect postpartum diuresis to begin approximately 12 hr after birth. Therefore, a urine output of 3,000 mL in 24 hr is an expected finding for this client.

A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching?

Your fluid intake will be limited to no more than 125 mL per hr to prevent fluid overload.