Maternal Newborn Practice A
A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? (Use all the steps and list them in order) A) Clean the newborn's diaper area B) Wash the newborn's neck by lifting the newborn's chin. C) Wipe the newborn's eyes from the inner canthus outward. D) Cleanse the skin around the newborn's umbilical cord stump. E) Wash the newborn's legs and feet
CBDEA
A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain ? A) Decreased heart rate B) Chin quivering C) Pinpoint pupils D) Slowed respirations
Chin quivering Behavioral responses to a newborn's pain include facial expressions (for example, chin-quivering, grimacing, and furrowing of the brow)
A nurse is caring for a client who is 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? A) to estimate fetal weight B) to locate a pocket of fluid C) to determine multiparity D) to pre-screen for fetal anomalies
To locate the 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 fetal injury
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? A) Let me help you into a comfortable pushing position so you can begin bearing down. B) I am going to call the doctor to get a prescription for medication to ripen your cervix. C) I will give you some IV pain medicine to strengthen your contractions. D) Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.
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 caring for a client 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) decreased uterine contractions B) an increase in the clients hemoglobin levels C) a reduction in respiratory distress in the newborn D) increased production of antibodies in the newborn
A reduction in respiratory distress in the newborn BEtamethason is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.
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? A) Place warm, moist packs on the breast. B) Apply cabbage leaves to the breast. C) Wear a loose- fitting bra. D) Put green tea bags on the breasts.
Apply Cabbage leaves to breasts Plant Sterols and Salicylates from cabbage leaves can help to relieve swelling and discomfort caused by engorgement.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following? A) Emotional lability B) Focusing phase C) Cognitive restructuring D) Couvade syndrome
Emotional Lability The nurse should recognize and interpret the client's statements as an indication of emotional lability. Many women experience rapid and unpredictable 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 newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? A) Obtain an informed consent prior to obtaining the specimen B) Collect at least milliliter of the urine for the test C) Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen. D) Premature newborns may have false negative tests due to immature development of liver enzymes.
Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen.
A charge nurse is on a labor and delivery unit is teaching a newly licensed RN how to perform Leopold maneuvers. Which is the first step?
Eveidence-based practice indicates that the first step the nurse should perform should be palpating the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect (Select all that apply) Heart Rate 154/min Axillary temp 36 C Respiratory rate 58 /min Length 43 cm Weight 2.6 kg
Heart Rate Respiratory Rate Weight HR has expected range of 110-160/min while awake Axillary temp should average 37 with a range of 36.5 to 37.5 C Respiratory rate is expected to be from 30-60/min Length expected range from 45-55 cm Weight is expected to range from 2.5 kg to 4 kg
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? A) maintain the client NPO throughout the procedure B) place client in a supine position C) instruct the client to massage the abdomen to stimulate fetal movement D) Instruct the client to press the provided button each time fetal movement is detected
Instruct the client to press the provided button each time a 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 movement will ensure that the fetal movement is noted.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? A) Acrocyanosis B) Transient strabismus C) Jaundice D) Caput succedaneum
Jaundice: (Correct) Jaundice occurring within the first 24 hours of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Acrocynanosis: bluish discoloration of the hands and feet and is an expected finding in a newborn 12hrs after birth. Transient strabismus: is a normal variation in the newborn's eyes that can persist until 4mo of age Caput Seccedaneum: is a benign, edematous area of the scalp and is commonly found on the occiput.
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) ? A) just above the umbilicus B) just above the symphysis pubis C) the right lower quadrant D) the left lower quadrant
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 pelivs slightly above the symphysis pubis. Therefore, the nurse should begin assessing for the FHTs just above the pubis.
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? A) administer aspirin for pain B) maintain the client on bed rest C) massage the affected leg every 12hr D) apply cold compresses to the affected calf
Maintain the client on bed rest The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a PE.
A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? A) swelling of the face B) varicose veins in the calves C) nonpitting 1+ ankle edema D) Hyperpigmentation
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 intramuscular compartment into the tissues.
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take? A) Take photos of the newborn to give to the parents. B) Tell the parents that they can consider organ donations. C) Encourage the parents to avoid allowing older children to visit them in the hospital. D) Explain to the parents the need to name the newborn
Take photos of the newborn to give to the parents The nurse should create a memory box that would include mementos of the newborn for example photos, ID bands, newborn's hat, and the newborn's blanket.
A nurse is assessing 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? A) Large for gestational age B) Hyperglycemia C) Bradypnea D) Vomiting
Vomiting Expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations usually last 2 days.
A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? A) You can miss your period for several other reasons, describe your typical menstrual cycle. B) If you have been sexually active and havent used protection, it is likely that you are pregnant. C) Lets check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet? D) Because you have missed your period, you should try taking a home pregnancy test before you start worrying.
You can miss your period for several other reasons, describe your typical menstrual cycle. amenorrhea (absence of a menstrual cycle) 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 providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A) you should get a 2 hour oral gluscose tolerance test in 6-12 wks B) you should avoid using low dose oral contraceptives for birth control C) you will need to monitor your blood glucose levels daily at home for 2-3 wks D) you will need to take a lower dose of insulin than you took during your pregnancy
You should get 2 hour oral glucose tolerance test in 6-12 weeks.