Maternal Newborn Practice B Assessment 2024: 100 Questions & Verified Answers, Exams of Nursing

Download Maternal Newborn Practice B Assessment 2024: 100 Questions & Verified Answers and more Exams Nursing in PDF only on Docsity!

MATERNAL NEWBORN PRACTICE B

ASSESSMENT 2024 /ACTUAL EXAM WITH 100

QUESTIONS AND VERIFIED ANSWERS WITH

RATIONALES /ALREADY A+

GRADED

A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a 4th degree perineal laceration. The nurse should contact the provider regarding which of the ff prescriptions? a. Docusate sodium 100mg PO TID b. Sitz bath 2 to 3x/day PRN for pain c. Bisacodyl rectal suppository PRN for constipation d. Ibuprofen 600mg PO q6h PRN for pain

• ANSWER>>c. Bisacodyl rectal suppository PRN for constipation RATIONALE: Should not administer a rectal suppository or enema to a client who has 4th degree perineal laceration. These can cause separation of suture line, bleeding, or infection. A nurse is preparing to administer Hep B immune globulin to a newborn. The rx states, "Administer 5mcg IM qday." Available is 5mL w/ 10mcg/mL. How many mL should the nurse administer? - ANSWER>>0.5mL A nurse is teaching a client who is at 8 wks of gestation about exercise. Which of the ff instructions should the nurse include in the teaching? a. Increase weight bearing exercises as pregnancy progresses b. Lie on your back to rest for 5 mins after exercising

c. Take pulse every 20mins while you are exercising d. Exercise for 30 mins each day. - ANSWER>>d. Exercise for 30 mins each day RATIONALE: Engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy A nurse is assessing a client who is in labor and notes early decels on the fetal monitor. Which of the ff findings should the nurse identify as a possible cause of the early decels? a. prolapsed umbilical cord b. placenta previa c. fetal head compression d. maternal hypotension

• ANSWER>>c. fetal head compression RATIONALE: Early decels are an expected fetal pattern caused by the fetal head compression due to uterine contractions, fundal pressure, and vaginal examinations. *Prolapsed umbilical cord: variable decels *Placenta previa and maternal hypotension: late decels A nurse is caring for a client and her partner who have experience a fetal death. Which of the ff actions should the nurse take? a. Take photos of the newborn to give to the parents b. Tell parents that they can consider organ donation c. Encourage the parents to avoid allowing older children to visit them in the hospital d. Explain to the parents the need to name the newborn.
• ANSWER>>a. Take photos of the newborn to give to the parents RATIONALE: Parents should create a memory box that includes mementos of the

newborn (photos, newborn's ID bands, hat, and blanket) A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the ff actions by the mother should the nurse recognize as a positive parenting behavior? a. lays the newborn across across her lap and gently sways. b. places newborn in the crib in a prone position c. offers the newborn a pacifier dipped in formula d. prepares bottle of formula mixed w/ rice cereals

• ANSWER>>a. lays the newborn across across her lap and gently sways. RATIONALE: This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn A nurse on an antepartum unit is caring for 4 clients. Which of the ff clients should the nurse identify as a priority? a. client who has gestational diabetes and a fasting blood glucose level of 120mg/dL b. client who is at 34 wks of gestation and reports epigastric pain c. client who is at 28 wks gestation and has an hgb of 10.4g/dL d. client who is at 39 wks gestation and reports urinary frequency and dysuria - ANSWER>>b. client who is at 34 wks of gestation and reports epigastric pain RATIONALE: Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the ff findings is an indication for the administration of the meds? Select all that apply.

a. Flaccid uterus b. Cervical laceration c. Excess vaginal bleeding d. Increased afterbirth cramping e. Increased maternal temperature

• ANSWER>>a. Flaccid uterus c. Excess vaginal bleeding RATIONALE: Oxytocin increases the contractility of the uterus and also decreases vaginal bleeding A nurse is teaching a new mother about newborn safety. Which of the ff instructions should the nurse include in the teaching? a. You can share your room w/ your baby for the next few weeks b. Cover baby w/ a light blanket while sleeping c. Check temp of the baby's bath water with you hand d. Baby can nap in her car seat during the daytime.
• ANSWER>>a. You can share your room w/ your baby for the next few weeks RATIONALE: Room sharing is recommended during the 1st few weeks. This allows parents to be readily available to the newborn and learn the newborn's cues. A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that her last menstrual cycle started on Nov. 27th. Which of the ff dates is the clien'ts expected date of birth? a. September 3rd b.September 29th c. August 3rd

d. August 20th

- ANSWER>>a. September 3rd RATIONALE: Subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the ff images indicates the first step of Leopold maneuvers? a. palpating in the lower abdomen to determine the attitude of the fetal head. b. palpating at the pelvic inlet to determine which fetal part is presenting in the pelvic inlet c. palpating at upper abdomen to determine which fetal part is in the uterine fundus. d. palpating the abdomen to determine the location of the smooth fetal back and the irregularly shaped, smaller fetal parts. - ANSWER>>c. palpating at upper abdomen to determine which fetal part is in the uterine fundus. RATIONALE: The nurse palpates the client's abdomen w/ her palms to determine which fetal part is in the uterine fundus A nurse is caring for a client who is at 38 wks gestation. Which of the ff actions should the nurse take prior applying an external transducer for fetal monitoring? a. determine progression of dilation and effacement b. perform Leopold maneuvers c. complete a sterile speculum exam d. prepare a nitrazine paper test - ANSWER>>b. perform Leopold maneuvers

RATIONALE:: 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 A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she had a moral issue w/ the client's decision. Which of the ff actions should the nurse manager take? a. Inform the staff nurse that she is required to care for the client. b. Advise the staff nurse that she will likely receive disciplinary action. c. Reassign the client to another staff nurse. d. Advise the staff nurse to transfer to another unit. - ANSWER>>c. Reassign the client to another staff nurse. R: The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. Therefore, the nurse manager should reassign the care of the client to another staff nurse. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the ff locations to begin assessing for the fetal heart tones (FHT)? a. just above the umbilicus b. just above the symphysis pubis c. right lower quadrant d. left lower quadrant - ANSWER>>b. just above the symphysis pubis R: At the end of the 1st trimester, the client's uterus is approx. the size of grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse

should begin assessing for FHTs just above the symphysis pubis. A nurse is planning care for a client who is undergo a nonstress test. Which of the ff actions should the nurse include in the place of care? a. NPO throughout the procedure b. Supine position c. Massage client's abdomen to stimulate fetal movement d. Instruct the client to press the button each time fetal movement is detected. - ANSWER>>d. Instruct the client to press the button each time fetal movement is detected. R: Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button for every fetal movement will ensure the fetal movement is noted. A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the ff? a. emotional lability b. focusing phase c. cognitive restructuring d. couvade syndrome - ANSWER>>a. emotional lability R: The nurse should recognize and interpret the client's statement as as indication of emotional lability. Many women experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate w/ feelings o joy or cheerfulness for little or no reason.

A nurse is caring for a prenatal client who has parvovirus B19 (5th disease). Which ff actions should the nurse take? a. Administer antiviral meds b. Schedule an ultrasound examination c. Administer haemophilus influenzae type b vaccine d. Schedule an indirect Coombs' test - ANSWER>>b. Schedule an ultrasound examination R: To monitor the fetus during pregnancy to detect the possible development of fetal hydrops. A nurse is caring for a client who is at 35 wks gestation and is undergoing a NST that reveals a variable decel in the FHR. Which of the ff actions should the nurse take? a. Give the client orange juice. b. Elevate the client's legs c. Have the client change position d. Establish IV access - ANSWER>>c. Have the client change position R: Having client change position is an appropriate intervention for a variable decel to relieve umbilical cord compression. A nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. Which of the ff non-pharmacological measures should the nurse include in the teaching? a. Use a breast binder to relieve discomfort. b. Use cold compress after each feeding c. Apply a few drops of colostrum to the nipple ff the feeding

d. Place breast shells inside the bra - ANSWER>>b. Use cold compress after each feeding R: Cold compress or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding. 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 ff statements should the nurse make? a. help client into a comfortable pushing position so client can begin bearing down b. call the doctor to get Rx for med to ripen cervix c. give some IV pain med to strengthen contractions d. insert intrauterine pressure catheter to monitor the strength of the client's contractions

• ANSWER>>d. insert intrauterine pressure catheter to monitor the strength of the client's contractions R: 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 A nurse in an antepartal clinic is providing care for a client who is at 26 wks gestation. Upon reviewing the client's medical record, which of the ff findings should the nurse report to the provider? a. 1 hr glucose tolerance test b. Hematocrit c. Fundal height measurement d. Fetal heart rate (FHR) - ANSWER>>c. Fundal height measurement R: Fundal height should be measured in cm and is the same as the number of gestational weeks plus or minus 2 wks 18 to 32 wks gestation

A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the ff findings should the nurse report to the provider? a. swelling of the face b. varicose veins in the calves c. non-pitting +1 ankle edema d. hyperpigmentation of the cheeks - ANSWER>>a. swelling of the face R: Swelling of the face, sacral area, and hands can indicate gestational HTN or preeclampsia. Reduction in renal perfusion leads to Na and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. A nurse in a prenatal clinic is assessing a group of clients. Which of the ff clients should the nurse request the provider see first? a. client who is at 11 wks gestation and reports abdominal cramping b. client who is 15 wks gestation and reports tingling and numbness in her R. hand c. client who is at 20 wks gestation and reports constipation for the past 4 days d. client who is at 8 wks gestation and reports having 3 bloody noses in the past wk. - ANSWER>>a. client who is at 11 wks gestation and reports abdominal cramping R: Client who is at 11 wks gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. A nurse is planning d/c for a client who is 3 days postpartum. Which of the ff nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? a. place warm, moist packs on the breasts b. apply cabbage leaves to the breasts

c. wear loose-fitting bra d. put green tea bags on the breasts - ANSWER>>b. apply cabbage leaves to the breasts R: Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. A nurse is reviewing the laboratory report of a client who is 24 hr postpartum ff a vaginal delivery. Which of the ff laboratory results should the nurse identify as an indication of a postpartum infection? a. Platelets 300,00/mm b. WBC 9,000/mm c. Erythrocyte Sedimentation Rate (ESR) 26mm/hr d. C-reactive protein 0.8mg/dL - ANSWER>>c. Erythrocyte Sedimentation Rate (ESR) 26mm/hr R: Value exceeds the expected reference range for a postpartum client and indicates an infection A nurse is assessing a newborn 12hr after birth. Which of the ff manifestations should the nurse report to the provider? a. Accryocyanosis

b. Transient strabismus c. Jaundice d. Caput succedaneum - ANSWER>>c. Jaundice R: Jaundice occurring within the first 24hr of birth is associated w/ ABO incompatibility, hemolysis, or Rh-immunization. The nurse should report this manifestation to the provider. Accrocyanosis: bluish discoloration of extremities, normal Transient strabismus: normal variation of newborn's eye until 4 months Caput succedaneum: benign, edematous area of scalp A nurse on postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the ff actions should the nurse take next? a. Massage the client's fundus b. Insert an indwelling urinary catheter c. Administer O2 at 10L/min d. Elevate the client's R. hip - ANSWER>>a. Massage the client's fundus R: Greatest risk to the client is hemorrhage. Next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. Indwelling catheter to monitor perfusion of the kidneys. O2 and elevate's R. hip enhance perfusion. A nurse is caring for a full-term newborn immediately ff birth. Which of the ff actions should the nurse take first? a. Apgar scores b. Weigh the newborn c. Place identification bracelets

d. Dry the newborn - ANSWER>>d. Dry the newborn R: Greatest risk to the newborn is cold stress. A nurse is teaching a client who is pregnant about managing N/V. Which of the ff instructions should the nurse include in the teaching? a. Brush your teeth immediately after eating b. Eat foods served at a warm temperature c. Drink a glass of water w/ each meal d. Eat high-carbohydrate foods - ANSWER>>d. Eat high-carbohydrate foods R: The nurse should instruct the client to eat high-carbohydrate (toast, potatoes, and rice) to decrease N/V. Avoid spicy, fatty, or fried foods. A nurse is assessing a client who gave birth vaginally 12hr ago and palpates her uterus to the R. above the umbilicus. Which ff interventions should the nurse perform? a. Reassess the client in 2hr b. Administer simethicone c. Assist the client to empty her bladder d. Instruct the client to lie on her R. side - ANSWER>>c. Assist the client to empty her bladder

R: Assessment findings indicate that the client's bladder is distended. This can prevent uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. Simethicone: reduce bloating, discomfort, or pain caused by excessive gas A nurse is caring for a client who is at 26 wks 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 ff actions should the nurse take immediately after the seizure? a. Monitor the FHR b. Assess uterine activity c. Administer O2 via a nonbreather mask d. Start a bolus of IV fluids - ANSWER>>c. Administer O2 via a nonbreather mask R: ABC's; place priority on administering O2 to the client to ensure adequate oxygenation to the fetus A nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. Which of the ff statement should the nurse make? a. Prevent unidentified visitors from entering the unit. b. Document the relationship of visitors in your medical record c. Baby will stay in the nursery while you are asleep d. Staff members who take care of your baby will be wearing a photo identification badge - ANSWER>>d. Staff members who take care of your baby will be wearing a photo identification badge A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the ff actions should the nurse include in the plan?

a. Feed newborn 1 oz water q4h b. Apply lotion to newborn's skin 3x/day c. Remove all clothing from newborn except diaper d. Discontinue therapy if newborn develops a rash - ANSWER>>c. Remove all clothing from newborn except diaper. R: Maximum skin exposure to UV light is needed to breakdown the excess bilirubin No water needed due to breastfeeding. No lotion or creams because it can led to burns. A temporary, fine rash can occur during phototherapy. A nurse in prenatal clinic is caring for a client who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the ff responses should the nurse make? a. "You can miss your period for several other reasons. Describe your typical menstrual cycle" b. If you have been sexually active and haven't used protection, it is likely that you are pregnant" c. "Let's check to see if you have any other signs of pregnancy. Have you noticed any enlargement yet?" d. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying" - ANSWER>>a. "You can miss your period for several other reasons. Describe your typical menstrual cycle" R: Amenorrhea is a presumptive sign, not a positive sign. The nurse should explore the client's menstrual cycle to determine other necessary interventions. A nurse is teaching a client who is Rh negative about Rh (D) immune globulin. Which of the ff statements by the client indicates an understanding of the teaching?

a. I will receive this med if my baby is Rh negative b. I will receive this med when I am in labor c. I will need a second dose of this med when my baby is 6 wks old d. I will need this med if I have an amniocentesis - ANSWER>>d. I will need this med if I have an amniocentesis Rh D immune globulin is given to Rh negative mothers ff an amniocentesis because of potential fetal RBCs entering the maternal circulation. Rh D immune globulin is given to Rh negative mothers who have Rh positive babies. It is administered at 28 wks gestation or after birth if newborn is Rh positive. A client who is at 34 wks gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the ff responses should the nurse make? a. Feel contractions primarily in upper abdomen b. Feel extremely fatigued when labor starts c. Breasts will begin to excrete colostrum d. Notice blood tinged discharge from vagina - ANSWER>>d. Notice blood tinged discharge from vagina R: Inform that a sign of true labor is bloody show, blood-tinged d/c from vagina that occurs when the cervix begins to efface and dilate. A nurse is caring for a client who is at 36 wks gestation and have positive contraction stress test. The nurse should plan to prepare the client for which of the ff diagnostic test? a. Biophysical profile b. Amniocentesis c. Cordocentesis

d. Kleihauer-Betke test - ANSWER>>a. Biophysical profile R: A positive contraction test indicates further evaluation of the fetus. A biophysical profile will provide further evaluation w/ real time ultrasound Amniocentesis: determine lung maturity, congenital anomalies, and diagnose fetal hemolytic disease Cordocentesis: identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia Kleihauer-Betke test: determine amount of fetal blood in maternal circulation. A nurse assessing the newborn of a client who took SSRI during pregnancy. Which of the ff manifestations should the nurse identify as an indication of withdrawal from an SSRI? a. LGA b. Hyperglycemia c. Bradypnea d. Vomiting - ANSWER>>d. Vomiting R: Expected clinical manifestations are irritability, agitation, tremors, diarrhea, vomiting, tachypnea, hypoglycemia, low birth weight. A nurse is assessing a newborn ff a circumcision. Which of the ff findings should the nurse identify as an indication that the newborn is experiencing pain? a. Decreased HR b. Chin quivering c. Pinpoint pupils d. Slowed respirations - ANSWER>>b. Chin quivering R: Behavioral responses to a newborn's pain include facial expressions (chin quivering,

grimacing, and furrowing of the brow). Other S&S are: increased HR, dilated pupils, and rapid and shallow respiration A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her L. calf. Which of the ff actions should the nurse take? a. Administer aspirin for pain b. Maintain client on bed rest c. Massage the affected leg q12h d. Apply cold compresses to the affected calf - ANSWER>>b. Maintain client on bed rest R: Client should remain on bed rest to decrease risk of dislodging the clot, which could cause a PE. Aspirin will increase risk of bleeding. No massages and warm compresses to promote circulation and decrease edema A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the ff statements should the nurse include in the teaching? a. Replace diaphragm every 5 yrs b. Leave the diaphragm in place for at least 6 hrs after intercourse c. Use an oil-based product as a lubricant when inserting the diaphragm d. Insert the diaphragm when bladder is full - ANSWER>>b. Leave the diaphragm in place for at least 6 hrs after intercourse R: Keep diaphragm in place to provide protection against pregnancy

A nurse is caring for a client ff an amniocentesis at 18 wks gestation. Which of the ff findings should the nurse report to the provider as a potential complication? a. Increased fetal movement b. Leakage of fluid from the vagina c. Upper abdominal discomfort d. Urinary frequency - ANSWER>>b. Leakage of fluid from the vagina R: It could indicate premature leakage of amniotic fluid and should be reported to the provider A nurse is teaching a new licensed nurse about collecting a specimen for the universal newborn screening. Which of the ff statements should the nurse include in the teaching? a. Obtain an informed consent prior to obtaining the specimen b. Collect at least 1mL of urine for the test c. Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen d. Premature newborns may have false negative tests due to immature development of liver enzymes - ANSWER>>c. Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen R: Nurse should ensure newborn has been receiving regular feedings for at least 24 hr prior to testing A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the ff findings should the nurse report to the provider? a. BUN 25 mg/dL b. Serum Creatinine 0.8 mg/dL

c. Urine output 280 mL w/in 8 hr d. Urine negative for ketones - ANSWER>>a. BUN 25 mg/dL R: Report elevated BUN to the provider since it can indicate dehydration A nurse is providing d/c teaching to a client who is postpartum and was taking insulin for GDM. Which of the ff instructions should the nurse include in the teaching? a. Get 2 - hr oral glucose tolerance test in 6 to 12 wks b. Avoid using lose does oral contraceptives for birth control c. Need to monitor blood glucose levels daily at home for 2 to 3 wks d. Need to take lower dose of insulin than you took during pregnancy - ANSWER>>a. Get 2-hr oral glucose tolerance test in 6 to 12 wks R: Instruct client to get a 2 - hr gtt 6 to 12 wks and every 3 yrs to screen for Type 2 DM A nurse is caring for a client who is anemic at 32 wks gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the ff outcomes should the nurse expect? a. Decreased uterine contractions b. Increase in client's hemoglobin levels c. Reduction in resp distress in the newborn d. Increased production of antibodies in the newborn - ANSWER>>c. Reduction in resp distress in the newborn R: Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent resp distress A nurse is teaching a client who is in preterm about terbutaline. Which of the ff statements by the client indicates an understanding of the teaching?

a. I will get injections of the medication once daily until my labor stops b. My blood sugar may be low while I'm on this medication c. I will have blood tests because my K might decrease d. My BP may increase while I'm on this med - ANSWER>>c. I will have blood tests because my K might decrease R: AE of Terbutaline is hypokalemia A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the ff laboratory results should the nurse report to the provider? a. Hct 39% b. Serum albumin 4.5 g/dL c. WBC 9,000/mm d. Platelets 50,000/mm - ANSWER>>d. Platelets 50,000/mm R: This is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. A nurse on the postpartum unit is caring for a client ff a cesarean birth. Which of the ff assessments is the nurse's priority? a. Parent-child attachment b. Amount of lochia c. Patency of IV catheter d. Quality and quantity of urine output - ANSWER>>b. Amount of lochia R: ABC's; The greatest risk to the client is bleeding and postpartum hemorrhage A nurse is teaching a client who is at 10 wks gestation about nutrition during pregnancy. Which of the ff statements by the client indicates an understanding of the teaching?

a. Increase protein intake to 60 g each day b. Drink 2 L of water each day c. Increase overall daily caloric intake by 300 cal d. Take 600 mcg of folic acid each day - ANSWER>>d. Take 600 mcg of folic acid each day R: Folic acid assists w/ preventing neural tube birth defects Protein intake: 71 g during 2nd or 3rd trimesters Water: 3 L Daily caloric intake: 340 cal/2nd trimester, 453 cal/3rd trimester A nurse is teaching a client who is at 35 wks gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the ff manifestations should the nurse include? a. SOB when climbing the stairs b. Edema on feet and ankle at the end of the day c. Headache that is unrelieved by analgesia d. Braxton Hicks contractions - ANSWER>>c. Headache that is unrelieved by analgesia R: Headache may indicate preeclampsia and should be reported to the provider A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the ff actions should the nurse take first? a. Determine resp function b. Increase IV fluid rate c. Access emergency meds from cart d. Collect maternal blood sample for coagulopathy studies - ANSWER>>a. Determine resp function R: ABC's; determine resp function and the need of CPR

A nurse is caring for a client who is in labor and whose fetus is in right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the ff actions should the nurse take? a. Apply sacral pressure b. Perform TENS c. Initiate slow-paced breathing d. Assist w/ biofeedback - ANSWER>>a. Apply sacral pressure R: Assist in relieving back labor pain r/t fetal posterior position TENS: 1st stage of labor Pattern-paced breathing is used for transition phase labor Biofeedback: prenatal period A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the ff cultural practices should the nurse include in the plan of care? a. Protect the client's head and feet from cold air b. Bathe client w/in 12 hr ff delivery c. Ambulate the client w/in 24 hr ff delivery d. Offer the client a glass of cold milk w/ her first meal - ANSWER>>a. Protect the client's head and feet from cold air R: Part of Hispanic practice during postpartum period. Also include: delaying bathing for 14 days ff delivery, bed rest for 3 days ff delivery, and drinking warm beverages ff birth. A nurse is performing a physical assessment of a newborn. Which of the ff clinical findings should the nurse expect? Select all that apply.

a. HR 154/min b. Axillary temp 36 deg C or 96.8 F c. RR 58/min d. Length 43 cm or 16.9 in e. Wt. 2.6 kg or 5 lb 12 oz - ANSWER>>a. HR 154/min c. RR 58/min e. Wt. 2.6 kg or 5 lb 12 oz R: HR 110 to 160/min while awake; RR 30 to 60/min; Wt. 2.5 to 4 kg (5.5 lb to 8.8 lb) Temp should be 37 deg C or 98.6 F: ranges are 36.5 to 37.5 deg C (97.7 to 99.5 F) Length is from 45 to 55 cm (17.7 to 21.7 in) A nurse is performing a routine assessment on a client who is at 18 wks gestation. Which of the ff findings should the nurse expect? a. DTR +4 b. Fundal height 14 cm c. Urine protein +2 d. FHR 152/min - ANSWER>>d. FHR 152/min R: Expected range for FHR is 110 to 160/min. FHR is higher earlier in gestation w/ an avg of approx 160/min at 20 wks gestation A nurse is planning to care for a client who is in labor and is to have an amniotomy. Which of the ff assessments should the nurse identify as the priority? a. O2 sat b. Temp c. BP d. Urinary output - ANSWER>>b. Temp R: Greatest risk for a client ff amniotomy is infection. Priority assessment is the client's

temp A nurse is caring for a client who is at 36 wks gestation and has a prescription for an amniocentesis. For which of the ff reasons should the nurse prepare the client for an ultrasound? a. To estimate the fetal weight b. To locate a pocket of fluid c. To determine multiparity d. To prescreen for fetal anomalies - ANSWER>>b. To locate a pocket of fluid R: Using ultrasound prior to amniocentesis decreases the risk of injury to the fetus A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the ff actions? a. Wash newborn's legs and feet b. Wash newborn's neck by lifting the newborn's chin c. Clean the newborn's diaper area d. Cleanse the skin around the newborn's umbilical cord stump e. Wipe the newborn's eyes from the inner canthus outward - ANSWER>>e. Wipe the newborn's eyes from the inner canthus outward b. Wash newborn's neck by lifting the newborn's chin d. Cleanse the skin around the newborn's umbilical cord stump a. Wash newborn's legs and feet c. Clean the newborn's diaper area A nurse is assessing a newborn who was born at 26 wks gestation using the New Ballard Score. Which of the ff findings should the nurse expect?