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Maternal Newborn Actual Exam Questions
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A nurse is caring for a client who is 8 hours postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply) a. Massage the fundus b. Give oxygen at 2L/min via nasal cannula c. Administer oxytocin d. Insert an indwelling catheter e. Place the client in a lateral position with her legs elevated 30 degrees - Solution Massage the fundus Administer oxytocin Insert an indwelling catheter Place the client in a lateral position with her legs elevated 30 degrees While assessing a client in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings would the nurse expect to see? a. The fundus is displaced from the midline b. The uterus is firm. c. The fundus is below the umbilicus. d. The bladder is resonant with percussion - Solution The fundus is displaced from the midline A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by holding the newborn upright with feet touching a flat surface? a. Babinski Reflex b. Moro Reflex c. Stepping Reflex d. Plantar Grasp Reflex - Solution Stepping Reflex The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see FIRST? a. A 2 day old infant who is lying quietly alert with a heart rate of 185 b. A 1 day old infant who is crying and has a bulging anterior fontanel
c. A 12 hour old infant who is being held, with respirations that are 45 breaths per minute and regular d. A 5 hour old infant who is sleeping and whose hands and feet are blue bilaterally - Solution A 2 day old infant who is lying quietly alert with a heart rate of 185 The nurse on a postpartum unit is preparing 4 clients for discharge. It would be MOST important for the nurse to refer which of the following clients for home care? a. A 15 year old primipara who delivered a 7 lb male 2 days ago b. An 18 year old multipara who delivered a 9 lb female by c-section 2 days ago c. A 20 year old multipara who delivered 1 day ago and is complaining of cramping d. A 22 year old who delivered by c-section and is complaining of burning on urination - Solution A 22 year old who delivered by c-section and is complaining of burning on urination The nurse teaches a primigravid woman how to measure the frequency of uterine contractions. The nurse should explain to the client that the frequency of uterine contractions is determined by which of the following? a. By timing from the beginning of one contraction to the end of the next contraction b. By timing from the beginning of one contraction to the end of the same contraction c. By the number of contractions that occur within a given period of time d. By the strength of the contraction at its peak - Solution By the number of contractions that occur within a given period of time Which of the following are presumptive signs of pregnancy? (Select all that apply) a. Positive pregnancy test b. Enlarged breasts c. Urinary frequency d. Braxton Hicks contractions e. Fetal heart tones heard by the provider f. Amenorrhea - Solution Enlarged breasts Urinary frequency Amenorrhea
a. Just below the xiphoid process b. At the symphysis pubis c. At the umbilicus d. Between the symphysis pubis and umbilicus - Solution At the symphysis pubis Upon assessment of a laboring patient, a nurse gathers the following information: cervical dilation of 5 cm, contractions every 5 minutes and moderate in strength along with some feelings of restlessness. What stage of labor is her patient in? a. Second Stage b. First Stage - Transition Phase c. Third Stage d. First Stage - Active Phase - Solution First Stage- Active Phase A nurse if providing education to a client who is 2 hours postpartum and has a perineal laceration. Which of the following information should the nurse include? (Select all that apply) a. Use a perineal squeeze bottle to cleanse the perineum b. Sit on the perineum while resting in bed c. Apply a topical anesthetic cream or spray to the perineum d. Wipe the perineum thoroughly with a back and forth motion e. Apply cold or ice packs to the perineum - Solution Use a perineal squeeze bottle to cleanse the perineum Apply a topical anesthetic cream or spray to the perineum Apply cold ice packs to the perineum Which of the following is a positive sign of pregnancy? a. Positive pregnancy test b. Fetus seen in ultrasound c. Abdominal enlargement d. Mild uterine cramping - Solution Fetus seen in ultrasound Upon cervical examination, the nurse finds that the umbilical cord is protruding from the patient's vagina. What should the nurse do? Select all that apply: A. Do the McRoberts maneuver B. Insert fingers into the vagina and move baby's head off the cord C. Position patient in Trendelenburg D. Instruct the patient to push
E. Call the provider immediately - Solution Insert fingers into the vagina and move baby's head off the cord Position patient in Trendelenburg Call the provider immediately A woman is admitted to the floor with the following obstetrical history: Delivered a daughter at 40 weeks, now 6 years old, had a miscarriage, delivered a son at 37 weeks, now 4, had a first trimester abortion one and a half years ago, and is currently pregnant. Which of the following portrays an accurate picture of this woman's gravidity and parity? A. G5 P B. G4 P C. G4 P D. G5 P2112 - Solution G5P Your patient was just diagnosed with HELLP Syndrome, but you don't remember what this condition entails. A charge nurse explains that HELLP Syndrome can be fatal to the mother and baby. What three conditions are included in the "HELLP" acronym? A. Low Liver functions B. Elevated liver functions C. Hematuria D. Low platelets E. Hemolysis - Solution Elevated liver functions Low platelets Hemolysis Which of the following are signs of postpartum psychosis? Select all that apply. A. Mood swings and irritability B. Disorientation and confusion C. Paranoia D. Thoughts of self-harm or harming the infant - Solution Disorientation and confusion Paranoia Thoughts of self-harm or harming the infant A nurse is teaching a new mother about bathing her infant. Which of the following statements indicate understanding?
b. External cephalic version c. McRobert's rotation d. External cephalic rotation - Solution External cephalic version What is the most ideal position for delivery? a. Right occipitoposterior (ROP) b. Left occipitoposterior (LOP) c. Right occipitoanterior (ROA) d. Left occipitoanterior (LOA) - Solution Left occipitoanterior (LOA) What shape of the mother's pelvis is the most ideal for a vaginal birth? a. Platypelloid b. Anthropoid c. Gynecoid d. Android - Solution Gynecoid A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? a. January 8th b. January 15th c. February 8th d. December 8th - Solution January 8th A nurse at a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? a. "This is due to an increase in blood volume." b. "This is due to pressure from the uterus on the diaphragm." c. "This is due to the weight of the uterus on the vena cava." d. "This is due to increased cardiac output." - Solution "This is due to the weight of the uterus on the vena cava." A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client? a. "You should wait until 4 weeks after conception to be tested." b. "You should be off medications 24 hours prior to the test." c. "You should be NPO for at least 8 hours before the test."
d. "You should collect urine from the first morning void." - Solution "You should collect urine from the first morning void." A nurse is caring for a G2P1 patient who is in the second stage of labor. The nurse notices that the fetal head retracts back into the vaginal canal after being delivered and knows this is an indication of shoulder dystocia. What action should the nurse anticipate? A.) Stop the oxytocin infusion B.) Turn the patient to the left side C.) Perform McRoberts maneuver D.) Encourage the mother to use additional force on with the next push - Solution Perform McRoberts maneuver The nurse knows which of the following are risk factors for umbilical cord prolapse? (Select all that apply) A.) Rupture of membranes B.) Breech fetal presentation C.) Maternal Hypertension D.) Placenta previa E.) Gestational Diabetes - Solution Rupture of membranes Breech fetal presentation Placenta previa When caring for a postpartum patient with type 1 diabetes mellitus, which of the following is most important that the nurse educate the patient to do after delivery? A.) Adjust insulin dosages to what they were pre-pregnancy. B.) Not to worry about blood glucose levels now the baby has delivered. C.) Keep her insulin dosages as they were during pregnancy until finished breastfeeding. D.) Get the infant screened for diabetes mellitus at the first newborn check up - Solution Adjust insulin dosages to what they were pre-pregnancy. You are assessing a newborn infant which has acrocyanosis, a good cry, minimal flexion and grimace, and whose heart rate is 110. Which of the following Apgar scores would you give the infant: a. 9 b. 4 c. 7 d. 6 - Solution 7
A mother in Labor and Delivery just delivered her baby via C-section. What are some complications the nurse should be mindful of? Select all that apply a. Increased chances of hemorrhaging b. Brain damage c. Possible incision infection d. Loss of appetite - Solution Increased chances of hemorrhaging Possible incision infection You are performing prenatal education with a client who is HIV positive. What piece of education should you be sure to include in the teaching? A- This patient must have a c-section B-This patient should not get pregnant again C- This patient should not breastfeed D- This patient doesn't need to take antiretroviral drugs during her pregnancy - Solution This patient should not breastfeed Which of the following are presumptive signs of pregnancy? (select all that apply) A-Breast tenderness B-amenorrhea C-insomnia D-fetal movements E-constipation - Solution Breast tenderness Amenorrhea Fetal movements A patient has come into the hospital and is in labor, she describes her contractions feeling like cramps and is 2 cm dilated, what stage of labor is she in? A-Stage 1- latent phase B-Stage 1- Transition phase C-Stage- D-Stage-4 - Solution Stage1- latent phase A patient in labor undergoing external fetal heart monitoring experiences several variable decelerations. The nurse understands this is caused by a. Head compress b. Cord compress c. Placental insufficiency
d. Neural tube defects - Solution Cord compress A nurse is caring for an infant who presents with Mongolian spots. What assessment findings should the nurse expect? (select all that apply) a. Bluish/purple spots b. Port wine stain c. Found on buttocks d. Frequently form on dark skin e. Sudden forming pink rash - Solution Bluish/purple spots Found on buttocks Frequently form on dark skin Which risk factors pose a greater risk for the development of dystocia in a laboring mother? (select all that apply) a. Multiple gestation b. Hydramnios c. Occiput anterior position d. Ineffective maternal pushing technique e. Maternal age of 23 - Solution Multiple gestation Hydramnios Ineffective maternal pushing technique Which of the following findings in a woman would be consistent with a pregnancy of two months in duration? a. Weight gain of 6-10 pounds and the presence of striae gravidarum. b. Fullness of the breast and urinary frequency. c. Braxton Hicks contractions and quickening. d. Increased respiratory rate and ballottement. - Solution Fullness of the breast and urinary frequency Which of the following are true regarding amniotic fluid? Select all that apply. a. Cushions the fetus from abdominal trauma. b. Serves as the fluid for the fetus. c. Decreases as the pregnancy advances. d. Maintains the internal temperature. e. Facilitates fetal movement. - Solution Cushions the fetus from abdominal trauma Serves as the fluid for the fetus Maintains the internal temperature
c. square window d. breast tissue e. arm recoil - Solution Eyes and ears Lanugo Breast tissue A newborn born a minute ago has a central paleness, a floppy mouth, bradypnea, vigorous cry, and flexed arms and legs. What is this newborn's first APGAR score? a. 3 b. 4 c. 2 d. 5 - Solution 4 A woman comes to the clinic complaining of a change from AUB to more bleeding. After assessing the woman. The nurse notes the woman's newborn is one month old. Which of the following statements will the nurse use to respond to the woman's situation? a. Bleeding is normal after pregnancy b. I will notify your provider c. It is normal to have cramping and some bleeding when breastfeeding d. Ovulation occurs anytime after 27 to 75 days influencing the action of menstruation and possible pregnancy - Solution Ovulation occurs anytime after 27 to 75 days influencing the action of menstruation and possible pregnancy You are providing teaching to a breastfeeding mom that is 2 days postpartum. When explaining to her the changes in her hormones after delivery, which of the following will you include? (select all that apply) a. Oxytocin will be released by your breasts when you feed your baby b. Estrogen increases when your uterus clamps down c. Prolactin decreases because it was released by the placenta which you delivered. d. Progesterone decreases e. hPL decreases to allow your insulin to work properly again - Solution Oxytocin will be released by your breasts when you feed your baby Progesterone decreases hPL decreases to allow your insulin to work properly again
A nurse is evaluating a postpartum client who is holding her baby. The client points to some pink marks on the baby's neck and eyelids and asks what they are. When assessing the newborn, the nurse finds that the marks blanch. What is priority action for this nurse? a. Tell the parent that they are port wine stains and will be there for the baby's entire life b. Inform the parent that it is nothing to worry about c. Tell the parent that they are stork bites and usually fade by the second year d. Notify the provider - Solution Tell the parent that they are stork bites and usually fade by the second year A primigravida client is coming in for her first prenatal appointment at 8 weeks pregnant. What would not be expected at this appointment? a. CBC blood draw b. Urinalysis c. Rhogam shot d. Ptyalism - Solution Rhogam shot Which of the following are signs/symptoms of postpartum hemorrhage? (Select all that apply) A. Boggy uterus B. Tachycardia C. Very small blood clots D. Hypotension E. Decrease in lochial discharge - Solution Boggy uterus Tachycardia Hypotension Which of the following are barrier methods of contraception? (Select all that apply) a. Intrauterine Device b. Diaphragm c. Tubal ligation d. Condom e. Spermicide - Solution Diaphragm Condom Spermicide
c. Fetal stage d. Embryonic stage - Solution Preembryonic stage Fetal stage Embryonic stage Which is not a part of the five Ps of labor? Select all those that apply a. Passageway b. Prepare c. Passenger d. Pain e. Position - Solution Prepare Pain What are the four parts of the contraction to assess? Select all that apply. a. frequency b. duration c. rhythm d. intensity e. uterine resting tone - Solution Frequency Duration Intensity Uterine resting tone A nurse is caring for a newborn immediately following birth. Which of the following is the nurse's priority intervention? a) bathe the infant b) give vitamin K injection c) dry and place a hat on the newborn d) give erythromycin ointment - Solution Dry and place a hat on the newborn A patient in labor is dilated to a 7 and is experiencing contractions every 3 to 5 minutes that last 40 to 70 seconds. What stage of labor is she in? a) Second stage b) First stage - active phase c) First stage - transition d) Fourth stage - Solution First stage- active phase A nurse is caring for a patient who recently found out that she was pregnant. She presents at the ED with unilateral stabbing pain in lower
abdominal quadrant and red vaginal bleeding. What condition does the nurse expect? a) Ruptured ectopic pregnancy b) Placenta Previa c) Spontaneous abortion d) Abruptio placentae - Solution Ruptured ectopic pregnancy A patient has a history of blood clots. Which type of birth control is contraindicated? a. Hormonal Methods b. Intrauterine Device (IUD) c. Barrier Methods d. Natural Family Planning - Solution Hormonal Methods Which of the following fetal positions is most favorable for birth? a. Frank Breech Presentation b. Transverse Lie c. Vertex Position d. Posterior position of the fetal head - Solution Vertex position You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient's APGAR score? a. APGAR 9 b. APGAR 8 c. APGAR 5 d. APGAR 10 - Solution APGAR 8 What are typical characteristics for SGA newborns? (Select all that apply) a. Increased subcutaneous fat stores b. Decreased subcutaneous fat stores c. Thin umbilical cord d. Loose dry skin e. Narrow skull sutures - Solution Decreased subcutaneous fat stores Thin umbilical cord Loose dry skin
A nurse is completing an admission assessment for a client who is at 38 weeks gestation and reports having been leaking vaginal fluid for the last few days. What is this client at risk for? a. Infection b. Hemorrhage c. Cord prolapse d. Placental abruption - Solution Infection A patient should contact her provider if she experiences which of the following postpartum? a. Sore nipples with cracks b. Decreased sexual arousal c. Uterine cramps during breastfeeding d. Scant, non odorous vaginal discharge - Solution Sore nipples with cracks A student nurse is shadowing a labor and delivery nurse. The student nurse asks the nurse what some contraindications are for circumcision. Which of the following are contraindications for circumcision? (Select all that apply) a. Epispadias b. Hypospadias c. Cryptorchidism d. Family history of hemophilia e. Hydrocele - Solution Epispadias Hypospadias Family history of hemophilia The nurse is looking at her patient's medical chart and notices that she has a favorable pelvis shape for delivery. Knowing this, which two pelvis shapes could the patient potentially have? (select all that apply) a. Gynecoid b. Platypelloid c. Android d. Anthropoid - Solution Gynecoid Anthropoid A NICU nurse is helping stabilize an infant immediately following birth. She notes acrocyanosis, weak cry, active movement, crying with stimulation,
and a pulse over 100 bpm. Based on these findings, what is the infant's APGAR score at this time? a. 8 b. 6 c. 10 d. 5 - Solution 8 A client checks into the labor and delivery unit for an eversion and the doctor has Terbutaline prescribed. What is the reasoning behind the order for this medication? a. To relax the uterus to prevent preterm labor b. To stimulate the uterus to help the baby turn into position c. To stimulate the uterus to help the mom go into labor after the baby is put in the correct position d. To relax all muscles of the body to help minimize the mom's comfort while the doctor rotates the baby - Solution To relax the uterus to prevent preterm labor A mom with preeclampsia comes into the clinic and complains of dizziness. What are some other important s/s to look for (select all that apply) a. urine output of 40 for the last 3 hours b. blurred vision c. nausea d. constipation e. nonreactive nonstress test - Solution Urine output of 40 for the last 3 hours Blurred vision Nonreactive nonstress test What are findings that need intervention for a newborn's APGAR score? (select all that apply) a. cyanosis b. heart rate 155 c. weak cry d. no kicking e. acrocyanosis - Solution Cyanosis Weak cry No kicking
