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Learning System PN 2.0 - Maternal Newborn Final
Questions With Complete Solutions
1. Nurse caring for client who desires IUD for contraception. Which finding is a
contraindication for the use of this device?
- HTN
- Menorrhagia
- Hx of multiple gestations
- Hx of thromboembolic disease: Menorrhagia - an IUD is a small plastic or copper device inside uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea or hx of ectopic pregnancy
2. Nurse reinforcing teaching to client who is pregnant. Which instruction should
nurse include?
- take 600mg of ibuprofen as needed for discomfort
- "You should eat soft cheeses to increase calcium intake"
- "You should roll your nipples daily to ensure they are everted"
- "You should use fluoride-based toothpaste to prevent dental caries.": "You should use fluoride-based toothpaste to prevent dental caries." - nausea during pregnancy can lead to poor hygiene and inflammation of the gingival tissue, which can lead to dental caries
3. Nurse assisting with the plan of care for a client who is pregnant and Rh negative.
In which of the following situations should the ruse administer Rh(D) Immune Globulin
- while the client is in labor
- following an episode of flu during pregnancy
- prior to a blood transfusion
- at 28 weeks gestation: 28 weeks gestation - Rh(D) immune globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in maternal circulation that blocks maternal newborn production
4. Nurse caring for a newborn who was born to a client who has narcotic use
disorder. Which action should the nurse identify as a contraindication in care of newborn?
- promoting maternal-newborn bonding
- tight swaddling
- small, frequent feedings
- frequent stimulation: Frequent stimulation - newborn needs quiet environment with minimal stimulation in order to promote rest and reduce stress. Stimulating environment can trigger irritability and hyperactive behaviors
5. Nurse caring for client 35 weeks gestation Which of the following lab tests should
the nurse obtain?
- Rubella titer
- blood type
- Group B strep
- 1hr glucose tolerance test: Group B streptococcus B-hemolytic culture - nurse should obtain vaginal/anal GBS culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic abx should be given during labor of the client with +GBS
6. Nurse assisting in plan of care for a newborn who requires phototherapy for
hyperbilirubinemia. Which of the following actions should nurse include in plan of care?
- swaddle the newborn in blanket
- maintain NPO
- check the newborn's glucose: continue to routinely monitor the newborn - normal resp rate and rhythm
10. A nurse is reinforcing teaching with a client who is postpartum and breast-
feeding. Which of the following nutrients should the nurse include in the teaching as a nutrient for the client to increase the intake of while breasting?
- Vitamin C
- Iron
- Folate
- Calcium: Vitamin C - important for tissue formation and integrity, nurse should instruct client to consume 115-120mg of vitamin C per day, which is an increase from when the client was pregnant
11. Nurse caring for the client who reports LMP began on July 8th, based on Nagele's
rule...what is the expected DOB?
- April 1
- April 15
- October 15
- October 1: April 15 - count back 3 mo from the first day of LMP and add 7 days
12. Client is 2 hr postpartum. Nurse notes that the client's perineal pad has a large
amount of lochia rubra with several clots. Which action should nurse take first?
- Check for full bladder
- Massage the fundus
- VS
- admin carboprost IM: Massage the fundus -> safety vs. risk -> primary cause of early postpartum bleeding is uterine atony m/b relaxed, boggy uterus
13. Nurse reinforcing d/c instructions with client following the removal of
hydatidiform mole. Which statement should nurse include?
- "Don't become pregnant for at least 1 year"
- "Seek genetic counseling for yourself and your partner prior to getting pregnant again."
- "You should have an hCG level drawn in 6 weeks."
- "Have your BP checked weekly next month.": "Do not become pregnant for at least 1 year." - increase r/f choriocarcinoma
14. A nurse is preparing a client who is pregnant for ultrasound. Which of the
following information is the most important for the nurse to collect?
- The time of the client's last void
- who will accompany the client to the ultrasound
- the date of the client's last menstrual period
- Whether or not the client wants to know the sex of the fetus: The time of the client's last void - client who is undergoing abd ultrasound require a full bladder for the test to be the most accurate -> full bladder helps to lift the gravid uterus out of the pelvis during exam
15. Nurse is reinforcing teaching with a client about a nonstress test. Which of the
following statements by the client indicates an understanding of the teaching?
- "I know not to eat after midnight."
- "I will have medication given to me to cause contractions."
- "I should press the button on the hand held marker when my baby moves."
- "I will have to stimulate my breast to cause contractions.": "I should press the button on the hand held marker when my baby moves."
16. Nurse assisting with care of newborn who has myelomeningocele. Which of the
following actions should the nurse take?
- Place the newborn in an infant carrier.
- Initiate a latex free environment
- Cover the sac with a large dry gauze
19. Nurse reinforcing teaching about oxytocin with a client who is in the third trimester
of pregnancy and has pre-eclampsia. Which of the following is a contraindication for use of this medication?
- Prolonged rupture of membranes at 38 weeks gestation
- Intrauterine growth restriction
- Active genital herpes
- Post term pregnancy: Active genital herpes - the use of oxytocin is contraindicated for clients who have active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore a cesarean birth is recommended for clients who have an active genital herpes infection.
20. A nurse is speaking with an expectant father who says that he feels resentful of
the added attention others are giving to his wife since pregnancy was announced several weeks ago. Which of the following responses should the nurse make?
- "Has your wife sensed your anger toward her and the baby?"
- "These feelings are common from expectant fathers in early pregnancy."
- "I'm sure that it's really hard to accept this when it's your baby too."
- "It would be wise for you to speak to a therapist about these feelings.": "These feelings are common for expectant fathers in early pregnancy." - the father needs reassurance that these feelings are expected. The nurse should reasssure him that when the pregnancy becomes obvious he will feel more involved.
21. Nurse is reinforcing teaching with a client who has active genital herpes simplex
virus, type 2. Which of the following statements by the nurse should be included in the teaching?
- "You will have your cesarean birth prior to the onset of labor."
- "Your baby will receive erythromycin eye ointment after birth to treat the infection."
- "You should take oral metronidazole for 7 days prior to 37 weeks of gesta- tion."
- "You should schedule a caesarean birth after your water breaks.": "You will have a cesarean birth prior to the onset of labor." - whenever possible, the caesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes
22. Nurse is caring for four newborns. Which of the following findings should the
nurse report to the provider?
- a 1hr-old newborn who has a blood glucose of 55mg/dL
- an 8hr-old newborn who has a resp rate of 50/min
- a 24hr-old newborn whose chest circumference is 32 cm
- a 12hr-old newborn who has the HR of 70/min while sleeping: A 12hr-old newborn who has. HR of 70/min while sleeping - avg HR for a newborn is 80-100/min while sleeping. A newborn's rate can increase to 180/min during episodes of crying. A HR less than 80/min is bradycardia and should be reported to the provider
23. Nurse who is assisting with the care of a preterm newborn who is receiving oxygen
therapy. Which of the following findings should the nurse identify as a potential complication of oxygen therapy.?
- Atelectasis
- Retinopathy
- Interstitial emphysema
- Necrotizing enterocolitis: Retinopathy -> oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. Retinopathy is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessel grow abnormally form the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness.
24. Nurse is reinforcing teaching about formula feeding with a parent of a newborn.
Which of the following statements by the parent indicates an under- standing of the teaching?
r/f hypoglycemia, other newborns at risk are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns and newborns who have perinatal hypoxia
27. A nurse administers betamethasone to a client who is at 33 weeks of gestation to
stimulate fetal lung maturity. When assisting with the plan of care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication?
- Hyperthermia
- Irritability
- Decreased blood glucose
- Rapid pulse rate: Decrease blood glucose - Betamethasone causes hyper- glycemia in the client, which predisposes the newborn to hypoglycemia in the first hours of delivery -> important to check glucose level within the first hr following birth and frequently thereafter until the blood glucose levels are stable
28. Nurse collecting data on a client who is 8 weeks of gestation. Which of the
following findings should the nurse report to the provider?
- WBC 14,000/mm
- Hgb 11.5 g/dL
- BP variation of 10mm Hg between arms
- Small amount of brown vaginal discharge: Small amount of vaginal discharge -> a small amount of brown vaginal discharge can be a warning sign of ectopic pregnancy. An ectopic pregnancy is where the fertilized ovum is implanted outside of the uterus. The nurse should report this finding.
29. A nurse is caring for the client who is at 16 weeks of gestation an has sever iron-
deficiency anemia. The provider prescribes and injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?
- Use a 20-gauge needle, and admin the medication using the z-track method
- Use a 22-gauge needle to administer the medication deep into the thigh
- Use a 25-gauge needle, and administer the medication into the deltoid muscle
- Use an 18-gauge needle, and administer the medication into the rectus femoris muscle: Use a 20-gauge needle, and admin the medication using the z-track method
30. Nurse caring for client who is at 8 weeks gestation with twins and is primigravida.
Client states that even thought she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make?
- "Have you told your husband about these feelings?"
- "These feelings are normal at beginning of pregnancy."
- "Perhaps you should see a counselor to discuss these feelings."
- "I am concerned about these feelings. Could you explain more?": "These feelings are normal at the beginning of pregnancy." -> the clients needs reassurance that these feelings are normal and no reason for concern
31. A nurse is prenatal clinic is caring for a client who is within the recommend- ed
guideline for weight. The client asks the nurse how much weight is safe for her to gain during pregnancy. Which response should the nurse make?
- "Your provider can discuss an appropriate amount of weight gain with you."
- "A weight gain of about 25-35 pounds is good."
- "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant."
- "A weight gain of about 14 pounds each trimester is suggested.": A weight gain of about 25-35 pounds is good - a weight gain of 25-35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each for the second trimester is recommended
diaphragm every 2 yrs." - flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. Rx-ed by MD and should be replaced every 2 yrs
35.A nurse in an anterpartum clinic answers a phone call from a client who is 37
weeks gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when i turned to my side." Which of the following should the nurse take?: Instruct the client about vena cava syndrome and measures to prevent it
- This is the typical finding of vena cava syndrome or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by the compression of the inferior vena cava by the gravity uterus with a consequent reduction in venous return. A side-lying position promotes uterine perfusion and fetoplacental oxygenation
36. Nurse is collecting date on a newborn who was born 43 weeks of gestation. Which
finding should nurse expect?
- Absent vernix
- abundant lanugo
- Increase subcutaneous fat
- Short, brittle nails: Absent vernix - white substance that covers the skin in newborn starting at 38 weeks gestation. Vernix keeps the skin soft and provides a protective barrier for the newborn. Post term will not have vernix.
37. Nurse is caring for a client who has clinical manifestations of ectopic pregnancy.
Which of the following findings is a r/f for an ectopic pregnancy?
- Anemia
- Frequent UTIs
- Previous cesarean birth
- Pelvic inflammatory disease: pelvic inflammatory disease - most cases are a result of scarring caused by a previous tubal infection or tubal surgery,
Therefore, pelvic inflammatory disease places client at risk
38. Nurse is preparing client to elicit the fencing reflex from a newborn. Which of the
following actions should the nurse take?
- Turn the newborn's head quickly to one side
- Clap loudly directly above the new born
- Tap the bridge of the newborn's nose when his eyes open
- Extend one of the newborn's leg and press down on the extended leg's knee: Turn the newborn's head quickly to on side - nurse will turn head quickly to one side, newborn will then extend the extremities in the direction he is facing with the opposite extremities flexing
39. Nurse is caring for client who is pregnant and reports N/V. Which of the
following instructions should the nurse provided to the client?
- "You should eat some crackers before rising from the bed in the morning."
- "You should eat foods served at warm temperatures."
- "You should sip whole milk with breakfast."
- "You should brush your teeth immediately after meals.": "You should eat some crackers before rising from bed in the morning." - dry foods before rising reduce nausea
40. Nurse is collecting data from a client on the first postpartum day. Findings include
fundus firm and one fingerbreadth above and to the right of he umbilicus, moderate lochia rubra with small clots, temperature 37.3C (99.2F), and pulse rate 52/min. Which of the following actions should the nurse take?
- Report the VS to provider
- Massage the fundus
- Ask the client when she last voided
- Obtain Rx for oxytocic agent: "Ask the client when she last voided." - full bladder
