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Maternal Newborn CMS PRACTICE SET
1. A nurse in a woman's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks
of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?: Iron. The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.
2. A nurse is caring for a client who has uterine hypotonicity and is experiencing
postpartum hemorrhage. Which of the following actions is the nurse's priori- ty?: Massage the client's fundus. Uterine hypotonicity and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, causing death to occur. Therefore, the nurse's priority is to massage the client's fundus in order to minimize blood loss.
3. A nurse is providing discharge teaching to a parent whose newborn has just had a circumcision. Which of
the following instructions should the nurse include?: Apply slight pressure with a sterile gauze pad for mild bleeding. The nurse should instruct the client to attempt to stop mild bleeding by applying pressure with sterile gauze. If bleeding continues, the client should notify the provider.
4. A nurse is teaching about effective breastfeeding to a client who is 3 days
postpartum. Which of the following information should the nurse include?: "Your newborn should appear content after each feeding." The nurse should inform the client that a baby who is sated will appear content after feedings. A baby who continues to show indications of hunger. For example, rooting,
2 / 16 sucking on the hands, or crying might not be ettectively emptying the breasts during feedings.
5. A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during
pregnancy. Which of the following statements by the client indicates an understanding of the teaching?: "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.
6. 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?: Contractions become stronger with walking. The contractions that occur during true labor become stronger and more regular with a change in activity, such as walking.
7. A nurse is teaching a group of parents about newborn safety. Which of the
following statements by a parent indicates an understanding of the teaching?- : "I will dress my baby in flame-retardant clothing." The parents should dress their newborns in flame-retardant clothing to prevent injury.
8. A nurse is assessing a client who is postpartum and has idiopathic throm- bocytopenia purpura (ITP). Which
of the following findings should the nurse expect?: Decreased platelet count. A client who has ITP has an autoimmune response that results in a decreased platelet count.
9. A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the
4 / 16 Applying an opaque eye mask prevents damage to the newborn's retinas and corneas
14. A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is
experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?: Transition. The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.
15. 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 history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.): Cholecystitis. A history of gallbladder disease is a contraindication for the use of oral contraceptive. contraindication for the use of oral contraceptives. Hypertension. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches. A history of migraine headaches is a contraindication for the use or oral contraceptives.
16. A nurse is assessing a client who is 12 hr postpartum. The client's fundus is
two fingerbreadths 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?: Assist the client to the bathroom to void.
5 / 16 A distended bladder inhibits the uterus from contracting normally and can cause uterine atony. Therefore, the nurse should assist the client to void.
17. A nurse is performing a physical assessment of a newborn upon admission
to the nursery. Which of the following clinical manifestations should the nurse expect? (Select all that apply.): Creases over two- thirds of the soles of the feet. Fewer creases over the soles of the feet is an indication of prematurity. Creases over the entire soles of the feet is an indication of postmaturity. Molding of the head. Molding occurs during the birth process as the newborn travels through the birth canal, resulting in compression of the soft bones of the skull. Lanugo on the shoulders. Absence of lanugo is an indication of postmaturity. Abundant lanugo is an indication of prematurity.
18. A nurse is developing an educational program for adolescents about nutri- tion during the third
trimester of pregnancy. Which of the following statements should the nurse include in the program?: "Consume three to four servings of dairy each day." Calcium intake is especially important during an adolescent's pregnancy because bone absorption of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume three to four servings of dairy per day to meet their calcium needs.
19. A nurse is performing a vaginal exam on a client who is in labor and reports
7 / 16 Placing the newborn skin to skin on the mother's chest is an ettective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.
23. A nurse is caring for a client who is to receive oxytocin to augment her labor.
Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?: Late decelerations. Late decelerations are indicative of uteroplacental insuflciency. Therefore, this is a contraindication for the administra- tion of oxytocin and should be reported to the provider.
24. A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of
the following findings should the nurse report to the provider?: Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.
25. A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative,
and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?: Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.
26. A nurse is 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?: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
8 / 16 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.
27. 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?: Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.
28. A nurse is assessing a late preterm newborn. Which of the following clinical
manifestations is an indication of hypoglycemia?: Respiratory distress. Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a clinical manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
29. A nurse is assessing four newborns. Which of the following findings should
the nurse report to the provider?: A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.
30. A nurse is preparing to perform 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.): Palpate the fundus to identify the fetal part.
10 / 16 infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider.
34. A nurse is assessing a client who is at 26 weeks of gestation. Which of the following clinical
manifestations should the nurse report to the provider?: De- creased urine output. Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be indications of preeclampsia and should be reported to the provider.
35. A nurse is caring for a client who is at 40 weeks 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 antici- pate?: Attention-focusing. Attention-focusing and distraction techniques are types of nonpharmacological care that are ettective in relieving labor pain.
36. A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr
glucose tolerance test. Which of the following statements should the nurse include in her teaching?: "A blood glucose of 130 to 140 is considered a positive screening result." The nurse should teach the client that a blood glucose level of 130 to 140 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.
37. A nurse is assessing a full-term newborn 15 min after birth. Which of the
following findings requires intervention by the nurse?: Respiratory rate 18/min. During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this time requires further evaluation and intervention by the nurse.
38. A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test.
11 / 16 Which of the following statements should the nurse include in the teaching?: "You will be ottered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain results.
39. 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?: "I'm sad for you." The nurse is ottering empathy to the client to facilitate further communication about the perinatal death.
40. A nurse is planning care for a client who is at 24 weeks of gestation and reports daily mild
headaches. Which of the following instructions should the nurse include in the plan of care?: Recommend that the client perform conscious relaxation techniques daily. The nurse should include conscious relaxation techniques in the plan of care as a way to relieve tension and reduce stress, which can help to decrease and eliminate headaches.
41. A nurse is performing a vaginal examination 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?: Assist the client to the hands and knees position. 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.
42. A nurse is caring for a client who is at 22 weeks of gestation and reports
concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?: Explain to the client this is an expected occurrence.
13 / 16 sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.
47. A nurse is teaching clients in a prenatal class about the importance of taking
folic acid during pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities?: Neural tube defect. The nurse should inform the clients that neural tube defects are more common in newborns born to mothers who had inadequate folic acid intake. Food sources of folic acid include fortified cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus.
48. A nurse is performing a newborn assessment. Which of the following images
should the nurse identify as an indication of spina bifida occulta?: The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.
49. A nurse is providing discharge teaching to the parents of a newborn about using a car seat properly.
Which of the following instructions should the nurse include?: Position the car seat rear-facing in the back seat of the vehicle. The nurse should instruct the parents to position 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 weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rear-facing in the backseat until they are 2 years old or reach the height and weight requirements of the car seat manufacturer.
50. A nurse is providing teaching to a client about the physiological changes that
14 / 16 occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?: "I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.
51. A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks
of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.): Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for delivery.
52. A charge nurse on the postpartum unit is observing a newly licensed nurse
who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?: The client's room number. Using the client's room number is not an acceptable identifier and places the client at risk for a medication error. Therefore, the charge nurse should intervene.
53. 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?: Petechiae over the head. Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.
54. A nurse is speaking with a client who is trying to make a decision about
16 / 16 The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.
58. A nurse is providing teaching about nonpharmacological pain management
to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?: Cold cabbage leaves. The application of fresh, raw cabbage leaves that have been chilled is an ettective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.
59. A nurse is providing discharge teaching to a client who had a cesarean birth
3 days ago. Which of the following instructions should the nurse include?: "You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.
60. A nurse is assessing a newborn who is 12 hr old. Which of the following
clinical manifestations requires intervention by the nurse?: Substernal chest retractions while sleeping. Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This clinical manifestation requires further assessment and intervention by the nurse.
