Maternal newborn practice B – Flashcards
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A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing o administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary id to identify the client?
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The client's room number R: is not acceptable identifier and places the client at risk for a med error
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A nurse is providing discharge teaching to a patient whose newborn has just had a circumcision. Which of the following instructions should the nurse include?
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Apply slight pressure with a sterile gauze pad for mild bleeding R: Nurse should instruct client to attempt to stop mild bleeding by applying pressure with sterile gauze. If bleeding continues the client should notify the provider.
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A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which of the following information should the nurse include?
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Your newborn should appear content after feeding R: If the baby is not content after feeding signs of hunger are rooting, sucking on the hands or crying because they might not be emptying the breasts during feeding completely
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A nurse planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
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Monitor the clients B/P every 5 min following the first dose of anesthetic solution B: The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution
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A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?
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Stop suctioning when the newborn cry sounds clear R: nurse should instruct client to stop suctioning when cry no longer sounds like it is coming through a bubble of fluid or mucus
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A nurse is assessing a client who is 12hr postpartum. The client's fundus is two finger breadths above the umbilicus deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?
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Assist the client to the bathroom to void R: a dissented bladder can cause the uterus from contracting and can cause uterine atony. Therefore, the nurse should assist the client to void.
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A nurse is reviewing the medical record at 1800 for a client who is at 34wks gestation. Based in the chart findings and documentation the nursing plan of care should include which of the following actions?
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Administer terbutaline R: administer terbutaline to stop contractions because the lab results indicate that the fetus's lungs are not mature enough for delivery
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A nurse is assessing a full-term newborn 15min after birth. Which of the following findings requires intervention by the nurse?
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Respiratory rate of 18/min R: first 30 min's of a newborns life the rest rate can range from 20-100/min. A resp. rate this low at the time requires further evaluation and intervention by the nurse
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A nurse us assessing a client who is at 26wks gestation. Which of the following clinical manifestations should the nurse report to the provider?
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Decreased urine output R: increased B/P, proteinuria and decreased fetal activity can be indication of preeclampsia and should be notified to the provider
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A nurse is providing teaching to a client about the physiological changes that occur during preg. The client is at 10 wks of gestation and has a BMI w/in the expected reference range. Which of the following client statements indicate an understanding of the teaching?
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"I will likely need to use alternative positions for sexual intercourse" R: The weight of the preg will change positions of sexual intercourse therefore understanding physiological changes during preg
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A nurse in a woman health clinic is providing teaching about nutritional intake to a client who is at 8wks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?
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Iron R: for the woman who are pregnant, it is 27 mg/day. the recommendations for woman not preg is 15/mg day, for women younger than 19 yr old and 18 mg/day for women between the ages of 19 and 50 years old.
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A nurse is assessing a client who is in active labor and notes early decelerations in the FHR on the monitor tracing. The client is at 39 wks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take?
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Continue monitoring the client R: early decelerations are due to fetal head during contractions, vaginal examinations and pushing during the second stage of labor. They are ok and normal
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A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first?
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Verify the newborn's ID R: for safety / risk reduction
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A nurse is providing education about the family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family 7-yr old in accepting the new family member?
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Obtain a gift from the newborn to present to the sibling
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A nurse is teaching a client who has pre-gestational type 1 DM about management during preg. Which of the following statements by the client indicates an understanding of the teaching?
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"I will continue to take my insulin if I experience n/v" R: Teach the client to continue to take insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes
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A nurse is providing d/c teaching to a client who is postpartum. For which of the following clinical manifestations should the nurse instruct the client to monitor and report to the provider?
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Unilateral breast pain R: can indicate mastitis an infection of the breast tissue s/s are chills, fever, malaise and unilateral breast pain
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A nurse is assessing a client who rec'd carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?
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HTN R: carboprost is a vasoconstrictor that can cause hypertension
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A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2-3 mins apart each lasting 80-90 seconds and a vaginal examination reveals that her cervix is dilated to 9cm. The nurse should identify that the client is in which of the following phases of labor?
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Transition R: this stage is characterized by a cervical dilation of 8-10 cm and contractions q 2-3 min each lasting 46-90 sec
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A nurse is teaching clients in a prenatal class about the importance of taking folic acid during preg. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to precent which of the following fetal abnormalities?
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Neural tube defect R: folic acid sources include fortified cereals, grain products, oranges, artichokes, liver, broccoli and asparagus
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A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
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You should take the medication w/in 72 hrs following unprotected sexual intercourse R: considered the emergency contraceptive which inhibits ovulation to prevent conception
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A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
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Place the newborn skin to skin on the mothers chest R: to decrease the newborn's pain level and anxiety, this should be implemented before, during, and aftre the procedure.
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A nurse is assessing a newborn who is 12hr old. Which of the following clinical s/s requires intervention by the nurse?
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Substernal chest retractions while sleeping R: can indicate rest distress syndrome in the newborn
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A nurse is caring for a client who is at 40 wks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?
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Attention-focusing R: Attention-focusing and distraction techniques are types of non-pharmacological care that are effective in receiving labor pain
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A nurse is providing d/c teaching to a client who had a C-section birth 3 days ago. Which of the following instructions should the nurse include?
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You can still become preg if you are breastfeeding R: breastfeeding does not prevent ovulation, nurse should discuss contraception that is safe to use while breastfeeding.
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A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following s/s should the nurse expect?
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Vaginal pressure R: the nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that lead into the tissues
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A nurse is caring for a client who has recently experienced a perinatal death. Which of the following statements should the nurse make to the client?
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"Im sad for you" R: the nurse is offering empathy to the client to facilitate further communication about the perinatal death
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A nurse is speaking with a client who is trying to make a decision about uterine tube occlusion. The client asks what effects will this procedure have on my sec life? Which of the following responses should the nurse make?
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This process should have no effect on your sexual performance or adequacy
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A nurse is teaching a group parents about newborn safety. Which of the following statements by a patent indicates an understanding of the teaching?
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I will dress my baby in flame retardant clothing R: The parents should dress their newbors in flame-retardant clothing to prevent injury
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A nurse is admitting a client to the labor and delivery unit when the client states. my water just broke. Which of the following interventions is the nurse's priority?
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Begin FHR monitoring R: The greatest risk to the client to the client and her fetus following a rupture of membranes is umbilial ord prolapse, The nurse should monitor the fetus closely to to esure well-being. Therefore. theis is the priority action the nurse should take.
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A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?
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The person who come sin to take my baby's pictures will be wearing a photo ID badge R: All personnel working on the unit should be wearing a photo identiication badge. The nurse should teach the mother to never allow anyone who is not wearing an identification badge to come in contact with her newborn.
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A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum hemorrhage. Which of the following actions is the nurses priority?
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Massage the client's fundus R: Uterine hypotonicty and postpartum hemorrhage indicate that his clinet is at the greatest risk for hypovolmic shock. The can compromise the perfusion to the clients vital organs, causing dweath to occur. Therefore, the nurses priority is to massage the clients fundus in order to minimize blood loss.
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A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
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A newborn who is 18 hr old and has an axillary temp of 37.7 (99.9F)
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A nurse is assessing a client who is at 38 wks gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?
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Weight gain of 2.2 kg (4.8lbs) R: a week is above reference range and could indicate complications
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Math A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available ts 20g magnesium sulfate in 500ml of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many ml/hr? (round to whole number)
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50ml/hr
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A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect?
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Petechiae over the head R: Nuchal cord or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head and neck
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A nurse is caring for a client who is to rec oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
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Late decelerations R: indicate uuteroplacental insufficiency. Therefore, this is a contraindiction for the administration of oxytocin and should e reported to the provider.
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A nurse is caring for a client who is at 22 wks gestation and reports concern about the blotchy hyper pigmentation of her forehead. Which of the following actions should the nurse take?
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Explain to the client this is an expected occurrence R: Melasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forhead. It is seen most often in dark-skinned women and is caused by an increase in melanotrin during pregnancy. This condition appears afetr 16 weeks of gestation and increases gradually until delivery for 50 to 70 % of women. Nurse should reassue the client that this is an expected occurance which usually fades after delivery.
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A nurse is assessing FHR for a client who is preg. The nurse has determined as left occipital anterior (LOA). To which of the following areas of the clients abdomen should the nurse apply the ultrasound transducer in order to assess the PMI of the fetal heart?
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Left lower quadrant R: The fetal heart tones of a fetus in the occipital anterior position are best heard in the left lower quadrant.
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A nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of preg. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
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Pregestional DM R: is a risk factor for developing preeclampsia. Other risk include, preexisting HTN, renal disease, systemic lupus erythematosus, and rheumatois arthritis.
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A nurse is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the nurse include when discussing true labor?
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Contractions become stronger with walking R: and more reg with a change in activity
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A nurse is developing an educational program for adolescents about nutrition during the third trimester of preg. Which of the following statements should the nurse include in the program?
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"Consume three to four servings of dairy each day" R: Calsium intake is especially important during an adolecents pregnancy because bone absorption of the calcium is still occurring. Therefore, the nurse shoukd instruct the adolesents to consume three to four servimg =s of dairy per day to meet their calcium needs
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A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. he nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best non-pharm intervention to perform to relieve the client's discomfort?
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Counter-pressure R: According to evidence-based practice, counter pressure is the best nonpharmacological technique to use when relieving the clients discomfort from the fetus being in a pisteroor position because this intrevention lifts the fetal head off of the spinal nerve.
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A nurse is assessing a late preterm newborn. Which of the following clinical manifestation is an indication of hypoglycemia?
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Resp distress R: is an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. S?S resp. distress is a clinical manifestation of hypoglycemia. Other manifestations o hypoglycemisa include an abnormal cry, jitteriness, lethargy, poor feeding, apnea and seizures
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A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following s/s should the nurse expect
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Creases over two thirds of the soles of the feet, molding of the head, lanugo on the shoulders R: fewer creases over the soles of teh feet is an indication of prematurity. Creases over the entire soles of teh feet is an indication of postmaturity. molding occurs during birth process as the newborn travels thouugh the birth canal, resulting in compression of teh sot bones of teh skull. absense of langugo is an indication of postmaturity. abundant lanugo is an indication of prematurity
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A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment?
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Demonstrate to the client how to perform a newborn bath R: Demonstrating the client how to perform a newborn bath occurs during the taking-hold phase. The new mother moves from being passively dependant to taking a stonger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment.
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A nurse is developing a plan of care for a client who has preeclampsia and is rec magnesium sulfate via a IV. Which of the following interventions should the nurse include in the plan?
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Monitor the FHR continuously R: Magnesium sulfate, which is used to prevent seizures in clients who have preclampsia, is a high-alert medicatio that require close monitoring, The FHR and uterine contractions should be monitored continuously while the client is reciving magnesium sulfate.
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A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
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Cover the newborn's eye's while under the phototherapy light R: Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherpy light.
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A nurse caring for a client who is at 15 wks of gestation, is Rh neg and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
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Monitor the FHR R: The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervension is to monitor the FHR following an amniocentesis
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A nurse is planing care for a client who is at 24 wks of gestation and reports daily mild headaches. Which of the following instructions should the nurse include in the plan of care?
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Recommend that the client perform conscious relaxation techniques daily R: The nurse should incliude conscious relaxation techniques in the plan of care as a way to relieve tenssion and reduce stress, which can help decrease and eliminate headaches.
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Nurse assess for spina bifida
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first picture
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A nurse is performing vaginal exam for a client who is in active labor and reports back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that the fetus is in the occiput posterior position. Which of the following actions should the nurse take?
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Assist the client to the hands and knees position R: The nurse should assist the client into the hands and knees position during contractions. This position can help relieve her back pain and it will enable the rotation of the fetus from the posterior to an anterior occiput position
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A nurse is teaching a client who is at 24 wks regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in her teaching?
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A blood glucose of 130-140 is considered a positive screening result R: The nurse should teach the client that a blood glucose level of 130 to 149 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus (DM)
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A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
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"I will eat foods that appeal to my taste instead of trying to balance my meals" R: Clients who have hyperemeis gravidrum should eat to taste to avoid nausea.
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A nurse is providing prenatal teaching to a client who is at 26 wks. Which of the following positions should the nurse recommend for the client to increase circulation to the placenta?
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Side-lying R: avoids compression of the vena cava, decreased circulation in the uterus can lead to having a child who is small for gestational age.
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A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives
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Cholecystjts, HTN, Migraine headaches R: cholecyctis- a history of gallbladder disease is a contraindication fro the use of oral contraceptives HTN- is a contrarindication Migrane headace- history of is a conraindication fro the use of oral conraceptives
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A nurse id assessing a client who is postpartum and has idioathis thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
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Decreased platelet count R: A client who has ITP has an autoimmune response that is a decreased platelet count.
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A nurse is teaching a client who is at 36 wks of gestation and has a rx for NST. Which of the following statements should the nurse include in the teaching?
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You will be offered OJ to drink during the test R: a nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stmulate the fetus during the procedure, helping to obtain results.
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A nurse is providing d/c teaching to the parents of a newborn about using a car seat properly. Which of the following instructions should the nurse include?
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Position the car seat rear-facing in the back seat of the vehicle R: The nurse should instruct teh parenrs to positon the car seat rear-facing in the back seat of the vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head and waek neck in the event of a suddent stop or colloision. Infabnts and toddlers should remain rear-facing inthe backseat until they are 2 years old or reach the height and weighht requirements of the car seat manufacturer.
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A nurse is providing teaching about non-pharm pain management to a client who is breast-feeding and has engorgement. The nurse should recommend the application of which of the following items?
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Cold cabbage leaves R: The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement.
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A nurse is preparing to preform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
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The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should detemine the location of the fetal back. Third, the nurse should palpate for the fatal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
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A nurse is preforming a newborm assessment. Which of teh following images should the nurse identify as n indication of spina bifida occulta? (images)
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R: the nurse should identify this image as spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defwect and the presence of a birthmark or hairy patch above the area. (Images of: mongolian spots, spina bifida manifesta in the form of a myelomeningocele that is open, and spina bifida manifesta in the form of a myelomeningocele that is closed)
