PN Maternal Newborn Online Practice 2020 B with NGN, PN Maternal Newborn Online Practice A
A nurse is reinforcing education about the prevention of newborn abduction with a client who recently gave birth. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"An alarm will sound if someone removes my baby's safety device."
A nurse is reinforcing discharge teaching about home care with the parent of a newborn. Which of the following instructions should the nurse include?
"Ensure the water temperature during your newborn's bath is maintained at 100 degrees Fahrenheit."
A nurse is reinforcing teaching with a client who has a new prescription for medroxyprogesterone acetate injection for contraception. Which of the following statements by the client indicates understanding of the teaching?
"I am likely to gain weight while taking this medication" rationale: a common adverse effect of this medication is weight gain
A nurse is assisting with the care of a client who is at 39 weeks of gestation. Which of the following statements should alert the nurse as a sign of a potential complication?
"I have pain in my upper right abdomen." Rationale: Epigastric pain can indicate hepatic involvement and severe preeclampsia.
A nurse is reinforcing teaching with a client who is 8 weeks gestation. Which of the following responses by the client indicates an understanding of the teaching?
"I should expect to have white vaginal discharge during pregnancy."
A nurse is discussing family planning with a client who is requesting information about available contraceptive methods. Which of the following client statements indicates an understanding of the teaching?
"I should use water-soluble lubricant when my parent wears a condom." Only water-soluble lubricants shuld be used with male condoms, because the use of any other lubricant may compromise the integrity of the condom.
A nurse is reinforcing teaching about breastfeeding with a client who has a 12 hour old newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I should wake my baby up to feed during the night" rationale: parents should awaken the newborn to feed every 3 hr at night for the first 24 to 48 hr after birth. once the newborn is gaining weight adequately progressing to demand feedings is safe.
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 instruction?
"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 care of my baby in the nursey if I need to take a nap."
A nurse is 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 clinet indicates an understanding of the teaching?
"I will lie on my left side with my head elevated on the pillow" Avoid lying supine during pegnancy to prevent supine hypotension. Uterus compresses the inferior vena cava in the supine position, which decreases blood pressure and casues dizziness and fainting. Lying on left side prevents compression of vena cava and subsequent hypotension
A nurse is reinforcing teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will position the retainer clip at the level of the baby's armpits." rationale: the guardian should position the retainer clip at the level of the newborn's axillae and not over the neck or abdomen
A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the clients understands the instructions?
"I will report any drainage from my baby's umbilical cord." rationale: the client should report any drainage or foul odor from the umbilical cord because these are manifestation of infection
A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"If my baby rides in a car with no back seat, the passenger air bag must be turned off."
A nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?
"Increase your fluid intake with this medication"
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 daughter's room. Which of the following responses should the nurse make?*
"Let me wash my hands and then I'll take your grandson to his mother." Only facility personnel with appropriate ID badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns.
A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements indicates an understanding of the teaching?
"This medication might make me dizzy."
A nurse in a provider's office is reinforcing teaching with a client. Which of the following statements should the nurse include?
"You might experience a metallic taste in your mouth while taking your medication." Rationale: A metallic taste in the mouth is a common adverse effect of metronidazole and does not warrant notification of the provider.
A nurse is reinforcing teaching about newborn home safety precautions with a group of guardians. Which of the following instructions should the nurse include?
"You should ensure that crib slats are no more than 2.25 inches apart." rationale:the nurse should reinforce that crib slats should be no more than 5.71 cm (2.25in) apart to prevent entrapment, which can lead to extremity fractures and suffocation
A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include?
"You will need to be in active labor during using hydrotherapy." The nurse should instruct the client that hydrotherapy is initiated once active labor begins. The use of hydrotherapy during the latent phase of labor can decrease the strength and frequency of contractions and slow the progression of labor.
A nurse is reinforcing teaching about nonstress test with a client who is at 33 weeks of gestation. Which of the following statements should the nurse include?
"You will press a button when you feel the baby move."
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 millilters per hour." The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid overload.
A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements is true?
"you must be at least at 37 weeks of gestation before you can use hydrotherapy."
A nurse is reinforcing teaching with a client who is trying to become pregnant. Which of the following foods should the nurse recommend as the best source of folate?
1 cup cooked spinach rationale: clients who are pregnant should consume 400mcg of folate per day. according to evidence based practice 1 cup of spinach provides 230mcg of folate and is the best of these nutritional sources for the nurse to recommend
A nurse is reinforcing teaching about food sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as a the best source of folate?
1/2 cup of dried peas
A nurse is assisting with the care of a client who is postpartum and is receiving lactated ringer's 1500 ml IV to infuse over 10 hr. The nurse should verify that the IV pump's settings will deliver how many mL/hr?
150 mL/hr
A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings shoudl the nurse report to the provider?
2+ urinary protein Manifestation of preeclampsia.
A nurse in a prentala clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider to see first?
A client who is at 37 weeks of 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 client who is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider?
Absent deep-tendon reflexes
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?
All 20 to 30 min for feedings.
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
A nurse is contributing to the plan of care for a newborn who has circumcised with a plastic bell device. Which of the following actions should the nurse include in the plan?
Apply pressure with sterile gauze if bleeding occurs at the site Frequently monitor for bleeding and apply gentle pressure using a sterile gauze square if bleeding occurs
A nurse is reinforcing teaching with a client who is pregnant and will undergo a 1-hr oral glucose tolerance test. Which of the following instructions should the nurse include?
Avoid caffeine the morning of the test
A nurse is collecting data about the client. Which of the following findings should the nurse report to the provider? Select all that apply. (A nurse is caring for a postpartum client.)
BP 152/105 mm Hg +2 pitting edema Headache Heartburn
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
A nurse is collecting data from a client who is at 36 weeks of gestaton during a prenatal examination. Which of the following findings should the nurse report to the provider?
Blurred vision
A nurse is collecting data from a client who is 37 weeks of gestation. Which of the following finding should the nurse report to the provider?
Blurred vision rationale the nurse should identify that blurred vision or double vision are manifestations of gestational hypertension or preeclampsia. the nurse should report this finding to the provider
A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching?*
Breastfeed the newborn baby at least every 2 hr. The nurse should instruct the client to breastfeed the newborn every 2 hr during engorgement. Frequent feedings soften the breasts and decrease pain.
A nurse is assisting with the care of a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. The client has a respiratory rate of 10/min. Which of the following medications should the nurse expect a charge nurse to administer to the client?
Calcium gluconate Antidote for magnesium sulfate toxicitiy
A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication?
Cessation of uterine contractions.
Complete the following sentence by using the lists of options. (A nurse is caring for a postpartum client.)
Check the clients deep tendon reflexes (DTRs) Check the client for visual disturbances
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 blood glucose leve. Collect data from the client
The nurse has reviewed the nurses' notes and the diagnostic results. Click to highlight the findings that indicate the client's condition is not improving.
Clonus positive. Deep tendon reflexes 4+ Reports headache as 4 on 0 to 10 pain scale. platelets 95,000/mm3 aspartate aminotransferase 60 units/L Alanine aminotransferase 50 units/L
A nurse is reinforcing teaching with the 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.
A nurse is collecting data from the parent of a newborn immediately following birth. The parent states she is so tiny. We don't know how to pick her up without hurting her. Which of the following actions should the nurse take first to promote parent-newborn attachment?
Demonstrate to the parent how to hold the newborn.
A nurse is collecting data from client who is a primigravida and has hyperthyroidism. Which of the following findings should the nurse expect?
Diaphoresis rationale diaphoresis, heat intolerance and tachycardia are expected findings with hyperthyroidism
The nurse should assist the RN in taking which of the following actions based on the most recent data collection findings? Select all that apply. (a nurse is assisting with the care of a client who is in labor)
Discontinue the magnesium infusion Administer calcium gluconate Apply oxygen at 10 L/min via nonrebreather mask
A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 hour following delivery?
Diuresis Discharge of clear, yellow fluid from the beasts Lower abdominal cramping
A nurse is contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend in the plan?
Drink 2L of water per day
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 pain 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 result. Which of the following actions should the nurse take?
Explain to the client that she will receive the hep B immune globulin immediately to decrease risk of transmission to fetus. Also instruct client that all sexual partners and members of the client's household should see their providers to begin prophylactic treatment
A nurse is assisting with monitoring a client after an amniocentesis. Which of the following findings should the nurse expect?
FHR 120/min
A nurse is collecting data form a 28 year old client who is requesting a prescription for an oral contraceptive. Which of the following information in the client's history should the nurse identify as a contraindication for the use of oral contraceptive?
Frequent headaches with visual changes
A nurse is collecting data from a client who is in her second trimester of pregnancy. Which of the following findings should the nurse report to the provider?
Frequent uterine contractions.
A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine prenatal visit. Which of the following findings in the data from the client's medical record should the nurse report to the provider?
Fundal height
A nurse is collecting data from a client who gave birth 18 hr ago. Which of the following findings should the nurse identify as an indication of a postpartum complication?
Fundus is palpable at 2 cm above the umbilicus.
A nurse is contributing to the plan of care for a client who is at 18 weeks gestation and has just learned that the fetus has trisomy 21. Which of the following resources should the nurse recommend for the client?
Genetic counseling rationale:a fetus that has 21 (down syndrome) has an extra chromosome. therefore the nurse should recommend genetic counseling to provide the client further education about the prognosis and treatment of the condition as well as offer support and guidance
A nurse is caring for a client following a cesarean birth. Which of the following should the nurse take to decrease the client's risk of developing thrombophlebitis?
Have the client ambulate several times each day.
A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort?
Have the client perform relaxing breathing techniques
A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort?
Have the client perform relaxing breathing techniques.
A nurse is caring for a client 6 hr after 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 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurses's priroity?
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 assis the client to empty her 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%
A nurse in an antepartum clinic is reviewing lab test results for a group of clients. The nurse should notify the provider of which of the following results?
Hematocrit 31% Rationale: Below the expected reference range for a client who is pregnant.
A nurse is caring for a client who has receive methylergonovine. Which of the folowing should the nurse identify and document as an adverse effect of the medication?
Hypertension Oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage. Can cause N/V, cramping, headache, and dizziness. Report changes in BP to provider because it can cause both hypertension and hypotension
A nurse is caring for a client who is in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take?
Inject the medication into the clients vastus lateralis muscle. Rationale: Administer the medication IM into the vastus lateralis muscle and administer a second dose 24 hr later.
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
A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes?
Intramuscular
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 reviewing the medication administration record for a client who is receiving nifedipine for gestational hypertension. The nurse should identify that which of the following medications is contraindicated for use with nifedipine?
Magnesium sulfate Magnesium sulfate is administered for the treatment of hypertension or to prevent seizures in clients who have preeclampsia. This medication is contraindicated for use with nifedipine because it can cause skeletal muscle blockade, resulting in muscle weakness or paralysis.
A nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend?
Monitor intake and output
A nurse is assisting with the admission of a newborn who has respiratory distress. While collecting data, which of the following should the nurse report to the provider? select all that apply
Nasal flaring Intercostal retractions Grunting
A nurse is assisting with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following images indicates a characteristic response of the tonic neck reflex?
Newborn's head is quickly turned to one side, the arm and leg on the same side extended, while the arm and leg on the opposite side flex.
A nurse is reinforcing teaching about formula preparation with the parent of a newborn. Which of the following information should the nurse include?
Overdiluted formula can result in inadequate growth
A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following findings should the nurse report to the provider?
Perineal pad soaked in 15 min Rationale: Perineal pad soaked in 15 minutes or less is a manifestation of postpartum hemorrhage.
A nurse is caring for a client who deliverd vaginally 6 hr ago. Which of the following findings should the nurse report to the provider?*
Perineal pad soaked in 15 min. The nurse should identify that soaking a perineal pad in 15 min or less is a manifestation of postpartum hemorrhage. Therefore, the nurse should report this finding to the provider.
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 To prevent damage to retinas. Remove mask for feedings
The nurse is reviewing the client's electronic medical record. which of the following actions should the nurse take? Select the 5 actions that the nurse should take.
Place client on seizure precautions assist with magnesium sulfate obtain the creatinine, platelet, BUN, and liver enzymes Check for worsening headache and epigastric pain Monitor level of consciousness, deep tendon reflexes, and visual disturbances check bp every 15- 30min
Based on the assessment findings, which of the following actions should the nurse take? Select all that apply. (A nurse is assisting in the care of a client who is in labor. The client's assessment and documentation are performed by the RN.
Place the client in Trendelenburg Provide oxygen at 8 to 10 L/min via nonrebreather Wrap the cord in warm, sterile, saline compresses
A nurse is reviewing the laboratory results of a 4 hr old newborn. Which of the folowing findings should the nurse report to the provider?
Platelet count 120,000/mm3 The nurse should identify that a platelet count of 120,000 is below the expected reference range of 150-300,000 for a new born. Therefore, the nurse should report this finding to the provider.
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 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 It can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse
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 planning to reinforce discharge teaching about formula feeding with the guardian of a newborn. Which of the following instructions should the nurse plan to include?
Provide the newborn with six to eight feedings during a 24-hr period.
Which of the following actions should the nurse plan to implement? For each potential action, click to specify if the intervention is indicated or contraindicated for the newborn. (A nurse is caring for a newborn)
ROM exercises on the affected arm after 1 week- indicated Check grasp reflex- indicated Immobilize the arm across the abdomen by pinning- indicated Limit physical handling for 2 weeks- contraindicated
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 collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider?
Respiratory rate of 10/min
The nurse is planning to administer terbutaline to a client who is experience preterm labor. Which of the following routes of administration should the nurse plan to use?
Subcutaneous Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication shuld be administered subcutaneously every 4 hr.
A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has repiratory distress. Which of the following findings should the nurse report to the provider?
Tachypnea Nasal flaring Retractions Expiratory grunting
Based on the nurse's findings, which of the following conditions is the client at the greatest risk for developing? (A nurse is caring for a postpartum client.)
The client is at the greatest risk for developing preeclampsia as evidenced by increased blood pressure.
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 clinet understands how to bathe her newborn?
The clinet washes the newborn's hair before unwrapping her
The nurse is planning care for the postpartum client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. (The nurse is reviewing the postpartum client's medical record.)
Urinalysis- anticipated I&O- anticipated Magnesium sulfate- anticipated Seizure precautions- anticipated Labetalol- Contraindicated (she has asthma) Creatinine and BUN- anticipated
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 3000 mL in 24 hr The nurse should expect postpartum diuresis to being approximately 12 hr after delivery. Therefore, a urine output of 3000 mL in 24 hr is exepected finding for this client.
A nurse on a postpartum unit is contributing to the discharge teaching plan of a client. Which of the following instructions should the nurse suggest for the plan?
Use a firm mattress in the newborn's crib
A nurse in a clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
Use an ultrasound stethoscope to listen for fetal heart tones.
A nurse is planning to administer phytonadione to a newborn. Which of the following actions should the nurse take?
Use the vastus lateralis as the injection site The nurse should inject phytonadione into the vastus lateralis because this is the most developed muscle in the newborn.
A nurse is caring for a client who is 48 hour postpartum following a vaginal birth. Which of the following findings should the nurse report to the provider? Select all that apply
Warm, tender are on the calf Dysuria Cracked nipples
A nurse is planning to perform a blood collection via heel stick on a newborn. After performing hand hygiene and donning gloves, which of the following actions should the nurse plan to take next?
Wrap the newborn's heel with a cloth moistened with warm water. Rationale: The nurse should first warm the newborn's heel by applying a cloth moistened with warm water for 5 to 10 min. This will allow dilation of the vessels in the area in order to obtain an adequate sample.
The nurse is reviewing the data collection findings. For each data collection finding, click to specify if the finding is consistent with a clavicle fracture or Erb-Duchenne paralysis. Each finding may support more than one condition. (A nurse is caring for a newborn)
clavicle- crepitus, birth history. Erb-Duchenne Paralysis- palmar grasp reflex, birth history, crepitus.
