RN Maternal Newborn Online Practice LATEST A+ VERIFIED

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RN Maternal Newborn Online Practice LATEST A+ VERIFIED 01. A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse's priori... ty? Amount of lochia When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage. 02. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? Apply sacral counterpressure The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. 03. A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck by lifting the newborn’s chin. Cleanse the skin around the newborn’s umbilical cord stump. Wash the newborn’s legs and feet. Clean the newborn’s diaper area. The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area. 04. A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take? Take photos of the newborn to give to the parents. The nurse should create a memory box that includes mementos of the newborn (for example, photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket). 05. A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with real-time ultrasound. 06. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. 07. A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. 08. A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Chin quivering Behavioral responses to a newborn's pain include facial expressions (for example, chin quivering, grimacing, and furrowing of the brow). 09. A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Vomiting Expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Tachypnea – Hypoglycemia -- Low birth weight 10. A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. 11. A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? Protect the client’s head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. 12. A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Perform Leopold maneuvers. The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer 13. A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? “Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.” Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor. 14. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? Massage the client’s fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. 15. A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions? Bisacodyl rectal suppository daily as needed for constipation The nurse should not administer a rectal suppository or enema to a client who has a fourth- degree perineal laceration. These can cause separation of the suture line, bleeding, or infection. 16. A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next? Administer oxygen via a nonrebreather mask. When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus. 17. A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? “You can miss your period for several other reasons. Describe your typical menstrual cycle.” Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. 18. A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? “You should get a 2-hour oral glucose tolerance test in 6 to 12 weeks.” The nurse should instruct the client to get a 2-hr oral glucose tolerance test 6 to 12 weeks postpartum and every 3 years to screen for type 2 diabetes mellitus 19. A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A client who is at 34 weeks of gestation and reports epigastric pain. Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. 20. A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.) Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. 21. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? Dry the newborn When using the urgent vs. nonurgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take immediately after delivery is to dry the newborn. 22. A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.) A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. A respiratory rate of 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb). 23. A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Progress Notes Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. 24. A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse. 25. A nurse is teaching a client about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? “I will need this medication if I have an amniocentesis.” Rho(D) immune globulin is given following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation. 26. A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? A reduction in respiratory distress in the newborn. Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. 27. A nurse is teaching a client who is at 8 weeks of gestation about exercise. Which of the following instructions should the nurse include in the teaching? “You should exercise for 30 minutes each day.” The nurse should instruct the client to engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy. 28. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. [Show More]

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