MATERNAL NEWBORN SOLUTION BANK 2024 LATEST| VATI RN Maternal Newborn 2019-2024| Question, Exams of Nursing

Download MATERNAL NEWBORN SOLUTION BANK 2024 LATEST| VATI RN Maternal Newborn 2019-2024| Question and more Exams Nursing in PDF only on Docsity! MATERNAL NEWBORN SOLUTION BANK 2024 LATEST| VATI RN Maternal Newborn 2019-2024| Questions &NGN Answers|100% Verified answers |Updated Version 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? 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. A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10 mcg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The nurse should administer hepatitis B immunoglobulin 0.5 mL IM. A nurse is reinforcing teaching with a guardian about how to care for the umbilical cord of their newborn infant. Which of the following statements by the guardian indicates a need for further teaching? I will give my newborn a bath once daily." The nurse should reinforce with the guardian to avoid giving the newborn a daily bath because it can damage the integrity of the newborn's skin. A nurse is reinforcing teaching with a client who is at 8 weeks of gestation and has chlamydia. Which of the following statements should the nurse include? "After treatment, you will need another test in 3 weeks and again between 35 and 37 weeks." The nurse should reinforce with the client that they will need to be retested for chlamydia 3 weeks after completing the prescribed regimen and again between 35 and 37 weeks of gestation. Most clients who have chlamydia are asymptomatic. Therefore, clients should be retested to identify potential reinfection, which would allow for additional treatment and decrease the risk for harm to the fetus during delivery. A nurse is reinforcing teaching with a client who plans to use a modified-paced breathing technique to relieve labor pain. Which of the following instructions should the nurse include in the teaching? "Begin and end modified-breathing with a deep cleansing breath. The nurse should instruct the client that all breathing patterns begin with a deep, relaxing, cleansing breath to "greet the contraction" and end with an exhaled deep breath to "blow the contraction away." Deep breaths ensure sufficient oxygenation for both the client and fetus. A nurse is reviewing the laboratory reports of four newborns. Which of the following laboratory results should the nurse report to the provider? Hgb 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of 14 to 24 g/dL for a newborn. The nurse should report this finding to the provider. A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers? Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with her palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus. 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? 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 has a moral issue with the client's decision. Which of the following actions should the nurse manager take? 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 following locations to begin assessing for the fetal heart tones (FHT)? At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a 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 to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that 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 following? The nurse should recognize and interpret the client's statement as an 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 with feelings of joy or cheerfulness for little or no reason. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? Having the client change position is an appropriate intervention for a variable deceleration 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 following nonpharmacological measures should the nurse include in the teaching? The nurse should suggest applying cold compresses or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding. A nurse is collecting data from an antepartum client who reports taking ferrous sulfate twice per day for the past month. The nurse should notify the provider of which of the following findings? Diarrhea The nurse should report diarrhea to the provider because it is a potential adverse effect of the medication. Diarrhea can lead to dehydration, which can cause preterm labor. This finding should be reported to the provider. A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings is the priority for the nurse to report to the provider? Saturated perineal pad within 15 min A saturated perineal pad within 15 min can indicate a cervical or vaginal tear. Therefore, the nurse should report this finding to the provider immediately. Anurse is collecting data from a newborn who is 6 hr old. Which of the following manifestations should the nurse expect? (Select all that apply.) Rust-stained urine is correct. A newborn's first void can contain uric acid crystals, which will give the urine a rust-stained appearance. Overlapping cranial sutures is correct. A newborn's cranial sutures should be palpable without evidence of fusion. Overlapping sutures can occur during a vaginal birth to allow passage of the fetus through the birth canal. Periodic breathing is correct. A newborn's respiratory effort is shallow and irregular and can have periods of 5 to 10 seconds with respiratory effort. A nurse is reinforcing teaching about daily fetal movement count with a client who is at 34 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching? 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 following a vaginal delivery. Which of the following laboratory results should the nurse identify as an indication of a postpartum infection? The nurse should realize that this value exceeds the expected reference range for a postpartum client and indicates an infection. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? 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. 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? 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. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? 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. A nurse is teaching a client who is pregnant about managing nausea and vomiting. Which of the following instructions should the nurse include in the teaching? The nurse should instruct the client to eat high-carbohydrate foods (for example, toast, potatoes, and rice) to decrease nausea and vomiting. The nurse should also instruct the client to avoid spicy, fatty, or fried foods. A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. 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? 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. 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 following statements should the nurse make? The nurse should teach the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of her newborn's safety. 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? 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. A nurse is contributing to the plan of care for a client who plans to formula feed their newborn. Which of the following interventions should the nurse recommend to include? Dilute concentrated formula with equal parts water. The nurse should instruct the client to dilute concentrated formula with an equal volume of water to provide the correct amount of nutrients to the newborn. Formula prepared with too little water is over concentrated and can provide protein and minerals in quantities that exceed the ability of the newborn's kidneys to excrete them, whereas formula prepared with too much water does not provide an adequate amount of calories for growth, A nurse is reinforcing teaching with a client who is at 11 weeks of gestation about a transvaginal ultrasound. Which of the following client statements indicates an understanding of the teaching? "i might feel some pressure when the probe is moved during the ultrasound." The nurse should instruct the client that a transvaginal ultrasound is not painful. However, the client might feel pressure when the provider moves the A nurse is reviewing the laboratory results for a client who has a BP of 156/102 mm Hg and is at 36 weeks of gestation. Which of the following laboratory values should the nurse report to the provider? Platelet count 100,000/mm The nurse should identify that a platelet count of 100,000/mm is below the expected reference range of 150,000 to 400,000/mm during pregnancy. A low platelet count can indicate HELLP syndrome; therefore, the nurse should report this laboratory value to the provider. A nurse is caring for a client who is 1 hr postpartum and has a third-degree perineal laceration. Which of the following actions should the nurse perform? (Select all that apply.) Apply an ice pack to the client's perineum is correct. The nurse should apply an ice pack to the client's perineum to decrease edema and promote comfort. A nurse in an antepartum clinic is reinforcing teaching with a client who is at 32 weeks of gestation and is scheduled for a nonstress test. Which of the following information should the nurse include in the teaching? "You will be asked to press a button when you feel your baby move during the test. The nurse should instruct the client to press a hand-held button attached to the monitor when they feel the baby move. Pressing the hand-held button will help to accurately correlate fetal movement with the fetal heart rate. A nurse is reinforcing teaching with the guardians of a newborn about the care of the umbilical stump. Which of the following instructions should the nurse include in the teaching? "Sponge bathe your baby until the umbilical stump has fallen off." The nurse should reinforce with guardians that submerging the umbilical stump in water can impede healing and promote infection. Therefore, the guardians should sponge bathe their newborn until the umbilical stump has fallen off. A nurse in an antepartum clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following findings should the nurse report to the provider? Weight increase of 3 kg (6.6 Ib) in one month The nurse should report a weight increase of 3 kg (6.6 normal prepregnancy weight should gain 1 to 2 kg (2.2 to 4.4 Ib) during the first trimester and 0.4 kg (0.9 Ib) per week during the second and third trimesters. Ib) in one month because this is excessive weight gain for the first trimester of pregnancy. A client with a A nurse is reinforcing teaching with a client who is pregnant and has iron deficiency anemia. Which of the following food sources should the nurse instruct the client to include in their diet to increase absorption of an iron supplement? Oranges The nurse should reinforce that consuming oranges, which are rich in vitamin C, enhances the absorption of iron supplements. The nurse should also instruct the client to take the supplement on an empty stomach. A nurse is assisting with the admission of a client who has pertussis and is at 28 weeks of gestation. Which of the following tyvpes of transmission- based isolation precautions should the nurse initiate for the client? Droplet The nurse should initiate droplet precautions for a client who has pertussis. Droplet precautions include a private room or cohorting of clients and the use of a mask when providing client care. Other infections that require droplet precautions include rubella, pneumonia, and influenza, A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10 weeks of gestation. Which of the following statements by the client indicates an understanding of the instructions? make sure that I get 1,000 milligrams of calcium per day." The client should consume a minimum of 1,000 mg of calcium daily during pregnancy to support fetal bone and tooth development. A nurse in a clinic is assisting with the plan of care for a client who is at 36 weeks of gestation. Which of the following actions should the nurse include in the plan of care? Obtain a culture for group B streptococcus B-hemolytic. The nurse should plan to obtain a rectovaginal culture to screen for group B streptococcus B-hemolytic infection in clients who are at 35 to 37 weeks of gestation. Group B streptococcus is present as normal vaginal flora in 25% of healthy clients who are pregnant. A positive culture requires treatment of the client during labor to prevent infection in the newborn. A clinic nurse is reviewing dietary instructions with a client who is at 20 weeks of gestation and taking iron supplements. Which of the following statements by the client indicates an understanding of the instructions? "I should increase my fluid intake while l am taking iron." The client should increase their fluid intake while taking iron to help lessen the occurrence of constipation, which is a common adverse effect of iron supplements. A nurse is assisting with collecting data from a newborn who is 4 hr old. Which of the following findings is the priority for the nurse to report to the provider? Generalized petechiae When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is generalized petechiae. This finding is a potential indication of a severe infection or a clotting factor deficiency and should be immediately reported to the provider. Hct 31% This hematocrit level is below the expected reference range of greater than 33% during pregnancy. The nurse should report this finding to the provider. A nurse is contributing to the plan of care for a client who is in labor and tested positive for group B streptococcus B-hemolytic. Which of the following interventions should the nurse include in the plan of care? Administer ampicillin via intermittent IV bolus. The nurse should administer ampicillin via intermittent IV bolus to the client who is positive for group B streptococcus B-hemolytic because transmission can occur during a vaginal birth, which can result in serious ilness in or death of the newborn. A nurse is planning to administer phytonadione IM to a newborn shortly after birth. The nurse should identify that this medication is administered to prevent which of the following complications? Hemorrhagic disease The nurse should administer phytonadione because the newborn does not produce vitamin K on their own until 7 days of age, when intestinal flora is present in the newborn's gastrointestinal tract. Therefore, this medication is administered to prevent hemorrhagic disease in the newborn until spontaneous production of vitamin K takes place. A nurse is assisting with the care of a client who is in active labor and notes late decelerations in the fetal heart rate, Which of the following actions should the nurse take first? Place the client in a side-lying position. When using the urgent vs. nonurgent approach to client care, the nurse should identify that late decelerations indicate a disruption of oxygen to the fetus. Therefore, the first action the nurse should take is to place the client in a side-lying position to maximize blood flow to the placenta and increase oxygen transfer to the fetus. A nurse in an antepartum clinic is collecting data from a client who is at 28 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication? Dysuria The nurse should identify that dysuria is an unexpected finding during pregnancy that can indicate a urinary tract infection. The nurse should report this finding to the provider. A nurse is assisting with the care of a client who is in the active stage of labor. For which of the following findings should the nurse notify the provider? Prolapsed umbilical cord The nurse should notify the provider immediately for a prolapsed umbilical cord because fetal hypoxia due to cord compression can occur. The occlusion of blood flow to and from the fetus can result in damage to the fetus's CNS and possible death to the fetus. A nurse on a postpartum unit is reinforcing information should the nurse include? teaching with an assistive personnel (AP) about preventing newborn abduction. Which of the following The AP should have their photo identification badge displayed. The AP should always wear their photo identification badge so that clients, staff, and families can easily identify them as hospital personnel who work on the A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian demonstrates an understanding of the teaching? "I will place my baby at a 45-degree angle in the car The newborn should be placed in the car seat at a 45° angle to prevent slumping and airway obstruction. The newborn will be unable to hold their head erect. Therefore, the newborn's head should be supported at all times. A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings indicates that the client is at risk for dehydration? Ketonuria Ketonuria indicates an excessive amount of ketones in the urine. When ketones are found in the client's urine, the initial indication is dehydration. Therefore, this is the most important initial laboratory test for clients who have hyperemesis gravidarum. The fluid volume deficiency and dehydration are directly related to excessive vomiting A nurse is caring for a postpartum client who has an episiotomy. Which of the following actions should the nurse take? Apply an anesthetic spray to the client's perineal area as needed for pain. The nurse should apply an anesthetic spray to the episiotomy site as needed to decrease pain. 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? 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 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? Behavioral responses to a newborn's pain include facial expressions (for example, chin quivering, grimacing, and furrowing of the brow). A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? The nurse should ensure that the 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 following findings should the nurse report to the provider? The nurse should report an elevated BUN to the provider since it can indicate dehydration. 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? 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 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? Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? An adverse effect of terbutaline is hypokalemia. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. An adverse effect of terbutaline is hypotension. An adverse effect of terbutaline is hyperglycemia. 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? 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. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. A WBC of 9,000/mm3 is within the expected reference range. A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse's priority? 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. A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A client who is pregnant should increase her folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. A client who is pregnant should increase her caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase her protein intake to 71 g each day during the second and third trimesters.