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Learning System RN 3.0 Maternal Newborn
Final Quiz verified questions and answers
A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take? - Answer Ask the client when she last voided
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? - Answer IV narcotics administered to the mother during labor
The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make? - Answer An epidural given too early can prolong labor
Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface.
A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client? - Answer You should eat some crackers before rising from bed in the morning
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin? - Answer At 28 weeks of gestation
The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? - Answer Respiratory depression
A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? - Answer Frequent stimulation
A nurse is caring for a client who is in labor. A vaginal examination reveals the following information: 2cm, 50%, +1, right occiput anterior. Based on this information, which of the following position should the nurse document in the medical record? - Answer Vertex
ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex.
A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device? - Answer Menorrhagia
An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care? - Answer Check the cervix prior to analgesic administration
A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan? - Answer You and your partner need to take the medication and use a condom during intercourse until cultures are negative
Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? - Answer Exaggerated reflexes
A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.
A nurse receives report on a client who is in labor and is experiencing contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? - Answer Contractions that last for 60 seconds each with a 3-minute rest between contractions
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? - Answer Pelvic inflammatory disease (PID)
An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there. The most common site is within a fallopian tube, but ectopic pregnancies can occasionally occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk for an ectopic pregnancy.
A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make? - Answer These feelings are quite normal at the beginning of pregnancy
A nurse is assessing a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? - Answer Obtain a stat prescription for a bilirubin level
A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? - Answer You will have a cesarean birth prior to the onset of labor
A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system? - Answer Blocks effects of narcotics on the CNS
A nurse in a prenatal clinic is caring for a client who is within the recommended guidelines for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? - Answer A weight gain of about 25-35 pounds is good
A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block? - Answer Hypotension-
Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? - Answer Do not become pregnant for at least 1 year
A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? - Answer Group B streptococcus B-hemolytic
The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS.
A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? - Answer My heart feels as if it is racing
The primary action of terbutaline is to cause bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority- setting framework, or nursing knowledge to identify which finding is the most urgent.
A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? - Answer Ensure the newborns eyes are closed before applying the eye shield
A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse make? - Answer We need to observe your baby more closely
A nurse is assessing a client who is receiving magnesium sulfate as treatment for preeclampsia. Which of the following clinical findings is the nurse's priority? - Answer Urinary output 40ml in 2 hours
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 the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? - Answer These feelings are common to expectant fathers in early pregnancy
The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious he will feel more involved. This therapeutic response addresses the client's feelings by providing information.
A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take? - Answer Perform continuous fetal heart rate monitoring
A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? - Answer I should replace my diaphragm every 2 years
The diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years.
The diaphragm should be rinsed with water and contraceptive jelly should be applied prior to placing the device into the vagina. Vaginal lubricants, mineral oil, and baby oil should not be used on the diaphragm, because they can weaken the rubber.
The diaphragm should remain in place at least 6 hr after intercourse.
A nurse is caring for a newborn who has irregular respirations of 52/minute with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? - Answer Continue to routinely monitor the newborn
A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? - Answer Retinopathy
Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness.
contraction stress test - Answer nipple stimulation to induce contractions
fetal alcohol syndrome - Answer exhibit respiratory manifestations such as tachypnea, nasal flaring, and chest retractions. Neurologic manifestations of FAS include irritability, tremors, and incessant crying. Gastrointestinal manifestations of FAS include uncoordinated sucking swallowing reflex, incessant hunger, and vomiting.
herpes - Answer "You will have a cesarean birth prior to the onset of labor."
Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.
