ATI – 2 Maternal and Newborn Qs – Flashcards
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A nurse is providing discharge instructions for a postpartum client who is breastfeeding. Which indicates further teaching?
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I will notify my doctor if my baby's skin begins to turn yellow. Serum billirubin levels continue to rise from birth until the fifth day of life. if the infant develops jaundice during this time, call the doctor Breastfeed q2 - 3 hrs during the day. Should awaken the baby at least q4 hrs during the night until baby is feeding well and gain weight adequately Infants doesn't receive vaccines till 2mths of age Nurses wear gloves to change diapers to AVOID cross contamination, not parents.
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A nurse is preparing to perform leopold maneuvers for a client. Identify the sequence the nurse should follow.
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1 - palpate the fundus to identify fetal part 2 - determine location of fetal back 3 - palpate the fetal part presenting at the inlet 4 - palpate the cephalic prominence to identify attitude of the head.
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A charge nurse is observing a newly licensed nurse who is administering pain medication to a client who had a vaginal delivery. The charge nurse should intervene when the newly licensed nurse uses which of the following to identify the pt?
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The clients room number - places client at risk for medication error OTHER. ways to ID telephone# birth date medical record #
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A nurse is preparing to administer 2mg IV bolus to a client. Available is butorphanol injection 1mg/mL. How many should the nurse administer?
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2mL 1mg / mL = 2mg / 2mL
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A nurse is assessing a client who is in early labor. The client is prepared for a labor assessment, the nurse should encourage....?
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The client to empty bladder - to accurately assess the uterus and fetal station, full bladder can displace the uterus and prevent descent of the fetus Other.... Partner can stay in the room entire labor Panting is not necessary till later labor stages when the urge to push is felt Pt placed in lithotomy position during pelvic exam, Sim's is for client who is disabled or deformed
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A nurse is in the birthing unit is caring for a newborn who is rooming in with her mother. Which of the following actions are consistent with the facilities safety plan for newborns?
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Comparing ID band w/ newborn parents. The newborn should never be left unsupervised Security band should be left in place till discharge - removing band is a violation of policy Parents should release the infant only to birthing unit employees w/ hospital badges w/ID
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A client who is pregnant arrives at the labor and delivery unit reporting leakage of fluid from the vagina. The nurse determines that the client has probable rupture of membranes when assessment reveals that....
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FERN test is Positive - fern-like pattern Nitrazine paper -pH Amniotic fluid is alkaline ;7.35 Premonitory sign of labor moderate bloody show is present. Occurs as the cervix begins soften, efface, dilate thick, white vaginal discharge present = candidiasis (yeast infection)
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A nurse is assessing a newborn who was born 12 hrs ago. Which findings requires an intervention by the nurse?
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Substernal retractions - sign of respiratory distress Positive babinski reflex - newborn should fan his toes when stroked in upward motion Acrocyanosis - bluish discoloration on hands and feet - expected first 24 hr following birth Audible murmur over base - or at 3 or 4 interspace of the left sternal border, normal variation in newborns
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A nurse is caring for a client who is at 27 wk gestation and has an elevated 1 hr 50g glucose screening result. The nurse should plan to initiate which for managing client care?
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Request a prescription for a 3 hr glucose tolerance test (GTT) Will NOT confirm GS 1 hr 50g -Glucose screening obtaining a serial blood glucose level for 24 hr repeating the test will yield same results
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A nurse is caring for a client who is 20hr postpartum. Which of the following is an appropriate intervention by the nurse? VS T - 37.8 C (100.0 F) P - 98/min R - 22 B/P - 110/62 Progress notes -Fundus palpable 1cm above the umbilicus and to the right -bowel sounds present in 4 quadrants -denies bowel movemnt Lab WBC - 23,000/mm3 Hct - 44% Hgb - 12.5g/dL
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Assist the client to void per notes - fundus displaced causing urinary retention
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A nurse is assessing a client who is 24 hr postpartum following a vaginal delivery. Which of the following lab findings indicates a postpartum infection?
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ESR - erythrocyte sedimentation rate 26 mm/hr NORM platelets - 300,000 mm3 WBC 9,000 mm3 C-reactive protein 0.88 mg/mL
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A nurse is caring for a prenatal client who expresses concern regarding her toddlers acceptance of the newborn. Which of the strategies should the nurse recommend?
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Give the toddler a t-shirt that say's "i'm the big brother" Parents should: introduce the toddler to the newborn in the hospital Give the toddler a gift encourage the toddler to participate in newborn care
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A nurse is caring for a client who is at 40 weeks gestation and receiving a NST. The monitor tracing shows a 15/min increased above baseline, lasting 15 seconds, in response to fetal movement two times in a 20-min period. Appropriate nursing action?
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Tell the client this is a reassuring finding - two or more accelerations in a 20 min period - reassuring NST Does not require ER c-section, CST, no need to continue another 10 mins
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A nurse is caring for a client who is at 26 wk gestation. Which findings should the nurse report to provider?
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Pitting edema of the ankles - may indicate preeclampsia Leukorrhea - hormone secretion - increased mucus - expected in 2nd trimester Supine HOTN - occurs as result
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A nurse is calculating a client's estimated date of delivery (EDD) using Nagele's rule. The client states that her last menstrual period began Aug 9th. What is the date?
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May 16 Add 9mths Add 7 days
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A nurse is caring for a postpartum client who is receiving continuous IV heparin therapy for thrombophlebitis in her left calf. Which of the actions should the nurse take?
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Maintain pt on bed rest - to decrease risk of pulmonary embolism AVOID massaging affected leg AVOID administering aspirin for risk of bleeding APPLY warm compress to affected area to promote circulation and decrease edema
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A nurse is caring for a client in the first stage of labor. The client has had no previous education about relaxation techniques and is experiencing pain during contractions. Which of the following should the nurse use to distract the pt?
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Effleurage - circular massaging movement Other: hypnosis - prenatal period biofeedback - prenatal period music therapy - planned ahead so pt can bring in music.
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A nurse is admitting a client to the postpartum unit who wants to practice traditional Hispanic cultural beliefs with delivery. Which of the following cultural practices should the nurse add to the plan of care?
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Protect the head and feet from cold air. Delay bathing for 14 days after delivery bed rest for 3 days after delivery drink warm beverages after birth
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A nurse is caring for a pt who has received epidural anesthesia during labor. While monitoring the client's vital signs, the nurse notices that she has become HOTN. After positioning the pt on her left side, which of the following is the priority nursing intervention?
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FIRST PRIORITY Increase the IV infusion rate: help stabilize maternal BP Can also help alleviate maternal BP: elevating pt legs administer O2 to improve perfusion vasopresser - ephedrine 5mg IV
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A client at 18weeks of gestation has had an abnormal serum alphafetoprotein and elects to have an amniocentesis for diagnostic confirmation. Which of the following statements by the client should the nurse recognize as indicating a complication ?
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"My stomach seems tight since the doctor left" Preterm labor and miscarriage is a potential complication following amniocentesis. Tightness indicates uterine contractions. Expected findings: movement of fetus fatigue - common discomfort of the first trimester pt should be NPO prior to procedure
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A nurse is caring for a client who has just delivered a newborn vaginally. The placenta has just been delivered when the client becomes non responsive. What following actions should the nurse take first?
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FIRST PRIORITY Determine respiratory function - ABC - Airway, breathing, circulation and may need CPR Following.... Increase IV fluid rate - maintain circulation Access emergency medication cart Collect a maternal blood sample in preparation for a blood transfusion
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A nurse is caring for a client who is being seen 2 weeks after a c- section. Which of the following findings should the nurse recognize as a possible sign of postpartum infection?
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Unilateral breast pain - symptom of mastitis - infection of breast tissue - experience chills, fever, malaise POSTPARTUM...... Lochia alba is expected finding at 2 weeks persist up to 6 weeks WBC count can rise as high as 25,000 mm3 especially 10 - 12 days after delivery w/out infection being present persistent abdominal striae are caused by the separation of the underlying connective tissue
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A nurse is providing education regarding management of diabetes during pregnancy for a pt who has type 1 DM and is receiving insulin. Which of the following statements by the client should indicate to the nurse a need for further teaching?
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I should eat most off my carbs at breakfast **Eat fewer carbs at breakfast than other meals for better blood glucose control SHOULD DO.... "include foods high in fiber in my diet" "eat 3-5x a day to avoid fluctuation in blood sugar" ref range 60-99mg/dL W/in range in pregnant and has diabetes
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A nurse is assessing a newborn. Which of the following are expected findings? select all that apply.
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CORRECT: HEART RATE: 154min = range 120 - 160/min RESPIRATORY: 58/min = range 30 - 60 WEIGHT: 2.6kg (5lb 12oz) = range 2.5 - 4kg INCORRECT Axillary temperature: 36C 96.8F = range 36.5 - 37.2 Length 43cm (16.9 in) = range 45 - 55cm
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A nurse is caring for a client who receives an opioid for pain relief. When assessing the client, the nurse notes a respiratory rate of 8/min. Nurse should administer?
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Naloxone - reverse opioid-induced respiratory depression in client. Other - Fentanyl - relief of severe, recurrent or persistent pain during labor Butorphanol - relief of labor pain, and postop pain C-section Meperidine - relief of severe persistent pain
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A nurse is assisting a client who is in the first stage of labor.. Which of the following actions by the nurse is appropriate in assisting the client with effleurage?
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Have the client stroke the abdomen using circular motions during contractions. Should assist client with selecting a focal point when using patterned paced breathing DO NOT provide heated blanket, apply firm, sacral pressure,
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A nurse in an ED is caring for a client who is at 9 weeks of gestation. The clients heart rate is 110/min, skin is cool, and clammy, and the client reports blurred vision, and headache. Steps in order.....
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FIRST ACTION: check glucose level offer the client 120mL 4oz of OJ Allow the client to rest for 15/min document the findings
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A nurse is teaching a client about newborn care. Which of the following instructions should the nurse include?
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Bathe the newborn every other day bathing daily causes dryness and alters the acid mantle of the newborns skin immerse newborn in bathe after the cord has fallen off keep bath temp at 36.6-37.2C 98 - 99F when cleansing only use warm water
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A nurse is providing teaching to a client who is 34 weeks gestation about possible complications of pregnancy. The nurse should instruct the client to report which of the following to the provider?
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Dull, intermittent back pain - clinical manifestation of preterm labor Expected findings 3RD trimester - interrupted sleep pattern increased anxiety 3-4 contractions/hour
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A nurse is assessing a client who has severe preeclampsia. Which of the following findings should the nurse expect?
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Blurred vision - photophobia 3+ DTR -deep tendon reflex proteinuria - 0.3g > oliguria - of 20mL/hr or less than 400 - 500mL in 24 hr
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A nurse is reviewing the health history of a recent admitted client who is in early labor. Contraindication to receiving nalbuphine?
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Opioid dependency - antagonist activity could precipitate w/d s/s NOT C/I smoking cigs allergy to hydromorphone gestational diabetes
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A nurse is performing a vaginal exam on a client who is at 38 weeks of gestation and in labor. The nurse notes the fetal head is in a posterior position. An appropriate non-pharmacological intervention to relieve pain for this client?
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Counter-pressure - lifts the occiput off the spinal nerves and provides
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A nurse is caring for a client who is hospitalized at 8weeks of gestation for hyperemesis gravidarum. Nurses First action?
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Start IV fluids, great risk for fluid and electrolyte imbalance May be administered: Total parenteral nutrition Be NPO first 24 to 48 hr
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A nurse is assigning an Apgar score to a newborn. The nurse notes that the newborn has a heart rate of 120/min is crying vigoriously with limbs flexed, has pink trunk, and has cyanotic hands and feet. Scores the nurse should document?
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9 Apgar score at 1 and 5 mins after birth. The nurse should document HR - 2 RR effort - 2 Muscle tone - 2 reflex irritability - 2 color - 1 ---------------------------> total 9
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A nurse is caring for a client who is 18 weeks of gestation and whose maternal serum alpha-fetoprotein (MSAFP) is high. Appropriate action of the nurse?
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prepare a prescription for an ultrasound - screening tool or neural tube defects that is effective between 15 - 22 weeks......further ultrasound examination and amniocentesis.
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A nurse is providing teaching to a client who has been exercising routinely for the first 5 months of her pregnancy. Indicate client understands the teaching??
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I will continue to swim throughout my pregnancy - non weight bearing activity cycling, stretching also recommended OTHER.. resting for 10min after exercise promotes circulation and blood flow to the placenta and fetus take pulse every 10-15 min while
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A nurse is caring for a client who is in early labor. The nurse observes the client tensing at the onset of contractions. Which of the following instructions regarding breathing techniques should the nurse provide to the client?
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Start taking a cleansing breath Other.... Suggest patterned breathing during transitional phase of labor
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A nurse is teaching the parent of a newborn about car seat safety. Which statement by the parent should indicate to the nurse a need for further teaching?
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Rear-facing until 2 yrs of age or child reaches the max height and weight recommended for the seat. OTHER... Turn off airbag if the newborn has to ride in the front seat. Secure car seat with vehicle seat belt Place car seat at 45 degree angle to prevent slumping and airway obstruction
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A nurse is planning care for a postpartum client. Which of the following is an appropriate intervention the nurse should use to promote maternal postpartum adjustment during the taking-hold phase?
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Demonstrating to the client how to perform a newborn bath Taking-hold phase, new mother focuses on care of the newborn and acquiring parenting skills.
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A nurse is working in an antepartum clinic is caring for a client who is at 41 weeks of gestation. A biophysical profile has been recommended. When educating the client about the test determines, which of the following should the nurse include?
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Fetal breathing movement Doppler blood flow - assess fetal blood flow amniocentesis - screens for fetal hemolytic d/o fetal chromosome analysis screens for karyotyping
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A nurse is providing discharge teaching to the parent of a newborn who had a circumcision using a plastiBell device. Which of the following should the nurse include in the teaching?
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Change the diaper at least every 4 hrs - to avoid penis sticking to diaper Plastibell usually falls off w/1 week DO NOT wipe away yellow exudate, its part of healing process w/in 24hr AVOID soap and water - irritation
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A nurse is caring for a client who has been prescribed RH immune globulin. Which of the following statements by the client should indicate to the nurse a correct understanding of the medication?
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The medication is to prevent blood incompatibilities in my next pregnancy. RH-neg SHOULD receive RH-immune globulin w/in 72hrs after giving birth to a RH+ to prevent development of antibodies that might harm the fetus during pregnancy. Baby does not receive a dose Tx is only one dose Does not prevent maternal anemia
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A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following is an appropriate action for the nurse to take?
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Allow the parents to hold the fetus - grieving process Encourage the client + partner the benefit of explaining and answering questions of the death of their sibling Explain to the client and partner that naming the baby may be helpful but not required Inform the client and partner its not necessary for an autopsy and allow them time to make the decision
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A nurse is caring for a client who is at 25 weeks gestation and in preterm labor. The nurse should recognize which of the following purposes for administering betamethasone to the client?
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Betamethasone - corticosterioids, increase the release of lung surfactant which improves fetal lung maturity to prevent or decrease respiratory distress syndrome in preterms babys 24-34 weeks of gestation. Receive two doses 12mg IM 24 HR apart DOES NOT decrease maternal anxiety decrease contraction rate in mom improve cardiac function
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A nurse is teaching a prenatal class about the importance of folic acid during pregnancy. The nurse should instruct the client to consume an adequate amount of folic acid to prevent ....?
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Neural tube defect - inadequate folic acid intake DOES NOT occur Trisomy-21 Cleft lip - common in mothers exposed to environment factors - infection/smoking atrial septal defect
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A nurse is completing a new ballard gestational age assessment of an infant who was born at 26 weeks of gestation. Which of the following should the nurse anticipate?
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Minimal arm recoil - decreased muscle tone laxity of muscles r/t prematurity, result in angle of 180 - 110 degree With increasing gestational age: a raised areola w/ 3 - 4mm bud, popliteal of 90 degrees indicates physical maturity with sole creases occur late in gestation and would be absent in preterm infants
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A nurse is reviewing the lab findings for a full term newborn who is 26 hr old. Should be reported to the provider?
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Total serum bilirubin 14mg/dL Newborn has 8 mg/dL or greater at 1 day of life and should receive phototherapy Expected findings in range Blood glucose - 45mg/dL Hct: 60% WBC - 10,000 mm3
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A nurse is caring for a client who is 3 days postpartum and planning discharge to home. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
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Apply cabbage leaves to the breasts - plant sterols and salicylates from cabbage leaves can help to relieve swelling from lactation DO NOT wear loose fitting bra put green tea bags on breasts place warm moist packs on breast
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A nurse is monitoring a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following assessment findings indicate a potential complication?
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irritability - manifestation of acute bilirubin and encephalopathy, serious complication Expected finding in Hyperbilirubinemia Brown or gold urine maculopapular skin rash yellow mucous membranes
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A nurse is teaching a client about breastfeeding. Client indicates understanding.....?
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I will hold my baby tummy to tummy when I'm feeding her - correct feeding and latching on Should latch on to the nipple + areola Feed on demand Average feeding is 15 - 20min each breast
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A nurse in a prenatal clinic is caring for a client who reports her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following is an appropriate response by the nurse?
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You can skip a period for other reasons, Describe your typical menstrual cycle. Amenorrhea is a presumptive sign
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A nurse is caring for a full term newborn immediately following delivery. Which of the following actions should the nurse take first?
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Dry the newborn - greatest risk is cold distress APGAR, ID, weight is shortly after birth
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A charge nurse on the labor and delivery unit is receiving report on four clients in various stages of labor. The charge nurse should plan to first assess the client who is experiencing which deceleration?
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Prolonged deceleration - result in fetal death if no response to intrauterine resuscitation. Charge nurse should notify the provider immediately and prepare for c-section if pattern is not corrected ***************************** Late - uteroplacental insufficiency may cause late decelerations and require nursing interventions including maternal position, increasing IV fluids, d/c oxytocin, administer 8 - 10 L of O2 via face mask Delivering the newborn if the FHR is persistent and does not respond Variable - cord compression Early - compression of fetal head during uterine contractions
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A staff nurse is precepting a nurse who is caring for a client at 32 weeks of gestation. The client is experiencing painless, vaginal bleeding. When reviewing the plan of care developed by the nurse, which of the following should the staff nurse question>
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Vaginal examination for cervical dilation - minimize stimulation to the placenta SHOULD DO..... Uterine palpation for tenderness and tone Assessment of amount and color of bleeding Insert IV catheter for fluid replacement
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A nurse is caring for an adolescent who is postpartum. Which of the following assessments should the nurse address first?
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Misinterpretation of infant feeding cues - great risk of inadequate nutritional intake OTHER..... Inability to diaper the infant correctly -> impaired skin integrity absence of emotional support system - adolescent will need support Reports fatigue - immediate response postpartum, should get adequate rest to recover
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A nurse is caring for a client who is receiving oxytocin for augmentation labor. The fetus is having a heart rate deceleration that begin and end suddenly and are v-shaped. What the priority action?
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Change the client's position - fetus at greatest risk for decreased uteroplacental perfusion from the umbilical cord compression. - relieve pressure on cord D/C oxytocin to stop contractions prepare for amninofusion if amniotic fluid is low admin O2 to promote uteroplacental perfusion
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A nurse is caring for a client who has preeclampsia and receives 2g magnesium sulfate IV bolus. Which of the findings indicate the need to notify the provider?
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Absence of DTR - indicates magnesium sulfate toxicity 150mL/over 4 hr A minimal of 30mL/hr urinary output Respiratory: 14/min =normal <12min - Mg sulfate toxicity Facial flushing - expected s/e initial bolus
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A nurse is caring for a postpartum client who is breastfeeding and has engorgement. Which of the following nonpharmacological comfort measure should the nurse include in teaching?
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You should use cold compresses after feeding - alleviate discomfort Applying drops of colostrum to the nipple following feeding helps sore nipples breast shells worn inside bra to promote circulation and prevent clothes touching sore nipples
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A nurse is caring for a client who has just delivered a newborn. The nurse is administering Oxytocin, which of the following findings indicate for use of Oxytocin?
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Flaccid uterus - increases contractility of the uterus Excess vaginal bleeding - enhance contractility and decrease bleeding INCORRECT: Cervical laceration - bleeding continues when uterus contracts and firms Increased afterbirth cramping - will increase Increased maternal temp - have no effect on temp
