Maternal Newborn Review Questions w/ Rationales P4

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

Breech Answer Rationale: An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth Answer Rationale: A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth.

A nurse is preparing to administer an injection of Rho (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications?

Hydrops fetalis Answer Rationale: Hydrops fetalis is the most severe form of Rh incompatibility and can be prevented by the administration of Rho (D) immunoglobulin.

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

Hyperinsulinemia Answer Rationale: High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant.

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.)

Indomethacin Magnesium sulfate

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

Insulin Answer Rationale: Insulin is the first line of treatment for clients who are pregnant and are unable to maintain blood glucose levels within the recommended range. Unlike oral hyperglycemics, insulin does not cross the placenta and affect the fetus.

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant?

Maintain oxygen saturations between 93% to 95%. Answer Rationale: Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?

Massage the client's fundus to promote contractions. Answer Rationale: A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness and light headedness can indicate that the client is at greatest risk for hypovolemic shock. Therefore, the next action the nurse should take is to massage the client's fundus to expel blood clots and promote uterine contraction to stop the bleeding.

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

Maternal/newborn blood group incompatibility Answer Rationale: Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.

A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?

Methylergonovine 0.2 mg IM now. Answer Rationale: Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification.

A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

Missed miscarriage Answer Rationale: With a missed miscarriage, the fetus has died but the client retains the products of conception for several weeks. The client might have spotting or no bleeding at all.

A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?

Necrotizing enterocolitis Answer Rationale: Premature newborns who are formula fed are much more likely to contract this acute inflammatory disease of the gastrointestinal mucosa.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Place the client in a lateral position Answer Rationale: Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

Place the newborn in the prone position. Answer Rationale: Placing the newborn in the prone position prevents trauma to the lesion. The newborn's knees should be assessed for evidence of skin breakdown.

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

Placental insufficiency Answer Rationale: Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Position the client on her side. Answer Rationale: Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?

Preparation for cesarean birth Answer Rationale: A cesarean birth is indicated for all clients who have a confirmed placenta previa.

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Answer Rationale: Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action?

Apply an external fetal monitor. Answer Rationale: Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Assess the fetal heart rate. Answer Rationale: The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?

Assess the odor of the amniotic fluid. Answer Rationale: Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid.

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

Asymmetric thigh folds Answer Rationale: Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH.

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

"I should remove extra blankets from my baby's crib." Answer Rationale: Loose bedding such as sheets and blankets could cover the baby's head and lead to suffocation.

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

"I will resume taking my prenatal vitamins." "I will call my provider if I have discharge from my incision." "I should not have unrelieved pain in my abdomen."

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

"It promotes fetal lung maturity." Answer Rationale: Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant.

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

"This could result in profound bleeding." Answer Rationale: "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.

A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

"This test requires the presence of amniotic fluid." Answer Rationale: Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation.

A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?

Projectile vomiting after feedings Answer Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the duodenum, resulting in projectile vomiting.

A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?

1) "Position the newborn at a 45-degree angle in the car seat." Answer Rationale: The nurse should instruct the parent to place the newborn at a 45° angle to prevent the newborn's head from falling forward and obstructing the airway.

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Contractions lasting longer than 90 seconds Answer Rationale: A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider.

A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives?

A 38-year-old client who reports smoking one pack of cigarettes every day Answer Rationale: A client who is over the age of 35 and smokes is at increased risk of thromboembolism.

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

Abruptio placentae Answer Rationale: The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions.

A nurse is instructing a male client about a semen analysis to be done for suspected infertility. Which of the following should be included in the teaching?

Abstain from ejaculation for at least 2 to 5 days prior to the test. Answer Rationale: The client should be instructed to abstain from ejaculation for at least 2 to 5 days prior to the test.

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

An excessive amount of amniotic fluid is present. Answer Rationale: An excess of amniotic fluid is defined as amniotic fluid pockets of >8 cm or an amniotic fluid index of greater than 25. Polyhydramnios or hydramnios is associated with neural tube defects, obstructions of the fetal gastrointestinal tract, multiple fetuses, and fetal hydrops.

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.)

Anomalies in fetal chromosomes Neural tube defects Fetal gender Anomalies in fetal chromosomes is correct. Examination of amniotic fluid yields data about genetic anomalies, such as hemophilia and inborn metabolic disorders. Neural tube defects is correct. Examination of alpha fetoprotein levels in amniotic fluid confirms the presence of a neural tube defect, such as spina bifida. Fetal gender is correct. Karyotyping of fetal cells obtained from amniotic fluid permits the identification of fetal gender, which is important if an X-linked disorder is suspected in a male fetus.

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Check the cervix prior to analgesic administration Answer Rationale: Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

Continuous contraction lasting 2 min Answer Rationale: A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?

Cullen's sign Answer Rationale: Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Deep tendon reflexes 4+ Answer Rationale: Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding. The nurse should also monitor for headaches, visual disturbances and epigastric pain. The provider will likely prescribe magnesium sulfate IV infusion.

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

Dilated scalp veins Answer Rationale: Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

Elevate her leg. Answer Rationale: The client should elevate her leg to encourage venous return and to relieve pain.

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Elevated blood pressure Answer Rationale: Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

Empty her bladder immediately prior to the procedure. Answer Rationale: Emptying the bladder before amniocentesis prevents possible puncture of the bladder and displacement of the uterus and fetus.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

Observe for crowning. Answer Rationale: In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Fundus palpable to right of midline Answer Rationale: Bladder distention results in uterine displacement, pushing the fundus above the umbilicus and away from the midline. The fundus might feel boggy to palpation and does not contract normally.

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Have the client ambulate. Answer Rationale: Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible.

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Heart rate 110/min Answer Rationale: A rapid or increasing heart rate can be a manifestation of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage.

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

Hypoglycemia Answer Rationale: Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse's priority focus of care.

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

Increased blood pressure in the arms with decreased blood pressure in the legs Answer Rationale: There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

Offer option to view products of conception. Answer Rationale: Providing support for pregnancy loss includes offering the client and her partner the options of viewing the products of conception and making arrangements for handling of the fetal remains. The client should be instructed on possible grief responses, how to manage these, and provided a referral to a support group.

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

Peanut butter Answer Rationale: The nurse should instruct the client to eliminate protein-rich foods that contain phenylalanine from the diet. These include meats, eggs, milk, nuts, and wheat products.

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?

Pelvic pain Answer Rationale: Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

Report of headache Answer Rationale: Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

Suction the mouth with a bulb syringe. Answer Rationale: The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect?

Systolic murmur Answer Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. A systolic murmur is a clinical manifestation found in newborns who have a large patent ductus arteriosus.

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. Answer Rationale: If the Rh-negative client has been exposed to Rh-positive fetal blood, she will produce antibodies against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh-positive fetus. This accelerated rate of red blood cell destruction results in the increased release of bilirubin. The newborn's serum bilirubin level can rise quickly

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

The mother plans to use a cotton-tipped swab to clean the nares. Answer Rationale: To prevent injury, the mother should use the corner of a washcloth to clean the newborns ears and nares.

A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.)

Transverse palmar creases Protruding tongue Transverse palmar creases is correct. A common characteristic of newborns who have Trisomy 21 is transverse palmar creases. Protruding tongue is correct. A common characteristic of newborns who have Trisomy 21 is protruding tongue.

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

Variable decelerations Answer Rationale: Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus.

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?

Wide skull sutures Answer Rationale: Newborns who are SGA have wide skull sutures due to inadequate bone growth. Head circumference is smaller than in a normal newborn and there is reduced brain capacity.