Maternal Newborn practice quiz 2

A nurse assessing a client who is a 4hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. Which of the following statements should the nurse make? a. "You might have retained placental fragments in your uterus." b. "Blood pools in the vagina when you are lying bed." c. "You might have a damaged blood vessel." d. "The amount of blood flow will increase during the first few days after giving birth."

"Blood pools in the vagina when you are lying bed." In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia.

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following statements indicates the nurse the client needs further instruction? a. "I can continue to breastfeed." b. "I will still need to have my provider perform a rubella titer check with my next pregnanct." c. "I cannot receive the rubella immunization during my pregnancy." d. "I can conceive anytime I want after 10 days."

"I can conceive anytime I want after 10 days." A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? a. "I will place my baby on his back when it is time for him to sleep." b. "I will keep my baby's crib close to the heat vents to keep him warm." c. "I will use an infant carrier when I drive to places close to my house." d. "I will tie my baby's pacifier around his neck with a piece of yarn."

"I will place my baby on his back when it is time for him to sleep." The newborn should always sleep on his back to prevent sudden infant death syndrome.

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? a. "I must drink milk every day in order to assure good quality breastmilk." b. "Drinking lots of fluids will increase my breast milk production." c. "After the first few weeks, my nipples will toughen up and breastfeeding won't hurt anymore." d. "It is normal for my baby to sometimes feed every hour for several hours in a row."

"It is normal for my baby to sometimes feed every hour for several hours in a row." Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8 to 12 times per day.

A nurse is assessing a 2 day old newborn and notes an egg shaped, edematous bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she inquires about the finding? a. "This will resolve within 3-6 weeks without treatment." b. "This will resolve on its own within 3-4days." c. "The provider might drain this area with a syringe." d. "This is expected at birth so you don't need to worry about it."

"This will resolve within 3-6 weeks without treatment." This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum, that will resolve within 2 to 6 weeks.

A nurse is preparing to andminister morphine oral solution 0.04mg/kg to a newborn who weighs 2.5kg. The amount available is morphine oral solution 0.4mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

0.25mL

A nurse is caring for a newborn who weighs 4lb. How many kilograms does the newborn weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1.8kg

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, and blue hands and feet. Which of the following is the Apgar score the nurse should assign to the newborn? a. 7 b. 8 c. 9 d. 10

9 he nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? a. Continuous lochia flow and a flaccid uterus. b. Report of increasing pain and pressure in the perineal area. c. A slow trickle of bright vaginal bleeding and a firm fundus. d. A gush of rubra lochia when the nurse massages the uterus.

A slow trickle of bright vaginal bleeding and a firm fundus. The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration. increasing pain and pressure in the perineal area to identify a vulvar hematoma.

A nurse is caring for a newborn who is premature at 30 weeks of gestation. Which of the following findings should the nurse expect? a. Abundant lanugo. b. Good flexion. c. Heel creases covering the bottom of feet. d. Dry, parchment like skin.

Abundant lanugo. Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.

A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take? a. Assist the client to ambulate in the hallway. b. Instruct the client to splint the incision with a pillow. c. Have the client drink fluids through a straw. d. Encourage the client to drink carbonated beverages.

Assist the client to ambulate in the hallway. Walking can help stimulate peristalsis, which will promote expulsion of gas. Drinking fluids through a straw can cause the client to ingest air and increase gas production.

A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temperature is 37.8C (100F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? a. Notify the provider about the elevated temperature. b. Assist the client to empty her bladder. c. Administer a bisacodyl suppository. d. Massage the client's fundus.

Assist the client to empty her bladder. When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.

A nurse is providing teaching to the parents of a newborn about bottle feedings. Which of the following instructions should the nurse include in the teaching? a. Dilute ready to feed formula if the newborn is gaining weight too quickly. b. Prop the bottle with a blanket for the last feeding of the day. c. Discard unused refrigerated formula after 72hours. d. Boil water for powdered formula for 1-2min

Boil water for powdered formula for 1-2min The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination.

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside? a. Naloxone b. Calcium gluconate c. Protamine sulfate d. Atropine

Calcium gluconate available to give to a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes

A nurse is assessing a 12 hour old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take? a. Perform chest percussion. b. Place the newborn in a prone position. c. Continue routine monitoring. d. Request a prescription for supplemental oxygen.

Continue routine monitoring. The nurse should continue routine monitoring because the newborn's assessments findings indicate he is adapting to extrauterine life.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? a. Apply the diaper tightly over the circumcision area. b. Remove the yellow exudate with each diaper change. c. Use prepackaged commercial wipes to clean the circumcision site. d. Encourage nonnutritive sucking for pain relief.

Encourage nonnutritive sucking for pain relief. Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 to 2 hr of delivery? a. Naloxone b. Erythromycin ophthalmic ointment c. Poracant alpha d. Rotavirus immunization

Erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth. Newborns who are premature receive poractant alpha, a surfactant replacement, to prevent and treat respiratory distress syndrome.

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? a. Urinary output. b. Blood pressure. c. Fundal consistency. d. Pulse rate.

Fundal consistency. Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is assessing a newborn 1 hr after birth. Which of the following assessment findings should the nurse report to the provider? a. Jaundice of the sclera b. Respiratory rate 50/min c. Acrocyanosis d. Blood glucose 60mg/dL

Jaundice of the sclera If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain. The nurse should expect a newborn to have acrocyanosis, a bluish discoloration of the hands and feet.

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect? a. Legs that are shorter than the arms. b. Temperature of one leg different from that of the other. c. Symmetrical gluteal folds. d. Limited abduction of one hip.

Limited abduction of one hip. A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum.

A nurse is caring for a postpartum client 8hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) a. Magnesium sulfate infusion b. Distended bladder c. Oxytocin infusion d. Prolonged labor e. Small for gestational age newborn

Magnesium sulfate infusion Distended bladder Prolonged labor Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? a. Terbutaline b. Nifedipine c. Magnesium sulfate d. Methylergonovine

Methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? a. Monitor the clients intake and output. b. Initiate a high-fiber diet for the client. c. Monitor the clients weight weekly. d. Initiate bedrest with the head of the bed elevated.

Monitor the clients weight weekly. The nurse should weigh the client daily to monitor for fluid overload.

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? a. Stand under a hot shower with your breasts exposed. b. Place ice packs on your breasts. c. Wear a loose fitting, comfortable bra. d. Limit fluid intake to 1 L per day.

Place ice packs on your breasts. The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body produces milk.

A nurse is assessing a 4 hour old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? a. Apply an oxygen hood over the newborn's head and neck. b. Check the newborn's temperature using a temporal thermometer. c. Place the naked newborn on the mother's bare chest and cover both with a blanket. d. Give the newborn glucose water between feedings.

Place the naked newborn on the mother's bare chest and cover both with a blanket. Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse take first? a. Perform a detailed physical assessment b. Place the newborn directly on the client's chest. c. Give the newborn Vitamin K IM. d. Administer erythromycin ophthalmic ointment.

Place the newborn directly on the client's chest. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? a. Rapidly advance oral feedings. b. Position the naked newborn on the parent's bare chest c. Provide frequent periods of visual and auditory stimulation d. Discourage the use of pacifiers

Position the naked newborn on the parent's bare chest This action can help maintain thermal stability, raise oxygen saturations, increase feeding strength, and promote breastfeeding.

A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the following findings should the nurse expect? a. Symmetric rib Cage. b. Dry, wrinkled skin. c. Vernix over the entire body. d. Lanugo abundant on the back.

Symmetric rib Cage. A newborn who is born at 39 weeks of gestation is full-term and should have a symmetric rib cage, have normal, smooth skin with good turgor and the presence of subcutaneous fat pockets.

A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. Rooting b. Moro c. Tonic Neck d. Babinski

Tonic Neck The newborn's arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? a. Offer the newborn glucose water between feedings b. Keep the newborns eye patches on during feedings. c. Apply barrier ointment to the newborn's perianal d. Use a photometer to monitor the lamp's energy.

Use a photometer to monitor the lamp's energy.