ATI - NUR 406 /NUR406 Maternal Newborn Assessment

Maternal Newborn Assessment 1. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse ta ...

Maternal Newborn Assessment 1. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take? Administer oxytocin to the client via intravenous infusion. Apply oxygen at 2 L/min via nasal cannula. Prepare for insertion of an intrauterine pressure catheter. Assist the client into the knee-chest position. 2. A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect? Hypotonicity Moderate tremors of the extremities Axillary temperature 36.1° C (96.9° F) Excessive sleeping 3. A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions? Non-Hodgkin's lymphoma Endometriosis Breast cancer Polycystic ovary syndrome 4. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion? Contraction frequency every 3 min Contraction duration of 100 seconds Fetal heart rate with moderate variability Fetal heart rate of 118/min 5. A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching? A peanut butter sandwich on wheat bread A sliced apple and red grapes A chocolate chip cookie with a glass of skim milk A scrambled egg with cheddar cheese 6. A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? BUN 35 mg/dL Hgb 15 mg/dL Bilirubin 0.6 mg/dL Hct 37% 7. A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicate an understanding of the teaching? "I will check the identication badge of anyone who removes my baby from our room." "I should include a photo of my baby along with any public birth announcements to social media." "I will allow my baby to sleep on the bed in my room when I am in the shower." "I should expect the nurses to carry my baby in their arms to the nursery." 8. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication? Periodic tingling of fingers Absence of clonus Leg cramps Blurred vision 9. A nurse is reviewing the laboratory results of a newborn who is 24 hr old. Which of the following findings should the nurse report to the provider? Hemoglobin 12 g/dL Glucose 50 mg/dL Bilirubin 4 mg/dL Platelets 200,000/mm 10. A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia? Polyuria Hypertension Pruritus Dry mouth 11. A nurse is teaching a client about using an intrauterine device (IUD) for contraception. Which of the following client statements indicate an understanding of the teaching? "I will need to have the IUD replaced each year." "I will need to apply a spermicide prior to intercourse." "I should expect my periods to stop while I have the IUD." "I should check for the string each month after menstruation." 12. A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider? Axillary temperature 36.5° C (97.7° F) Nasal faring Heart rate 158/min One void since birth 13. A nurse is assessing a client who gave birth 1 week ago. The client states, "I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason." The nurse should identify that the client is experiencing which of the following emotional responses to birth? Postpartum depression Taking-in phase Postpartum blues Taking-hold phase 14. A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply.) Nulliparity History of breastfeeding Previous use of oral contraceptives History of breast cancer Hormone replacement therapy 15. A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications? Abruptio placentae Hydatidiform mole Preterm labor Placenta previa 16. A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take? Request a prescription for PRN aspirin from the provider. Massage the injection site thoroughly following administration. Instruct the client that they cannot breastfeed while receiving heparin. Administer the injection in the client's abdomen. 17. A nurse is caring for a newborn whose father voices concerns about his ability to bond with his baby. Which of the following actions should the nurse take to facilitate bonding? (Select all that apply.) Point out to the father that the newborn turns toward his voice. Ask the father why he is concerned about bonding with the newborn. Encourage the father to touch and stroke the newborn's skin. Demonstrate diapering and swaddling techniques for the father. Encourage the father to lay the newborn beside him while both are sleeping. 18. A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include? "Increase potassium intake." "Increase fluid intake to 3 liters per day." "Decrease sodium intake before menstruation." "Decrease daily fiber intake." 19. A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take? Initiate continuous monitoring of the FHR. Administer a dose of betamethasone. Check the cervix for dilation every 8 hr. Request that the provider prescribe misoprostol PRN 20. A nurse is providing teaching to a client who is at 32 weeks of gestation and is experiencing stress incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) Decrease dietary fiber. Practice Kegel exercises. Restrict daily fluid intake. Reduce caffeine intake. Avoid daily exercise. 21. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first? Prepare the equipment necessary to initiate an amnioinfusion. Administer oxygen at 10 L/min via nonrebreather face mask. Discontinue the infusion of oxytocin. Place the client in a left lateral position. 22. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take? Restrict protein intake to less than 40 g/day. Initiate seizure precautions for the client. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr. Encourage the client to ambulate twice per day 23. A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take? Assist the client to void every 3 hr. Monitor contractions every 30 min. Place the client into a lithotomy position. Encourage the client to use a pant-blow breathing pattern 24. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings? Nevus ammeus Caput succedaneum Cephalohematoma Erythema toxicum 25. A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take? Encourage the mother to breastfeed the newborn. Gavage feed 60 mL (2 oz) of glucose water. Administer 10 mL of D W via IV. 10 Recheck the glucose level in 2 hr 26. A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome? Hyporeactivity Excessive high-pitched cry Acrocyanosis Respiratory rate of 50/min 27. A nurse is caring for a client who has placenta previa. Which of the following interventions should the nurse implement for this client? (Select all that apply.) Perform a vaginal exam. Monitor fetal heart rate with an internal fetal monitor. Frequently assess maternal heart rate. Initiate bed rest with bathroom privileges. Have oxygen equipment available. 28. A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy? Vitamin E Vitamin D Fiber Calcium 29. A nurse is teaching a pregnant client who is Rh-negative about Rh (D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? "If my partner is Rh-negative, I will not receive the shot." "I will receive the shot after delivery if my baby is Rh-negative." "I should not receive any immunizations for 3 months after the shot." "This shot may be given after birth to protect future pregnancies." 30. A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make? "You should keep the car seat rear-facing until your baby is at least 2 years old." "Position the retainer clip over the upper part of your baby's abdomen." "You should place your baby in the car seat at a 90-degree angle." "Place the shoulder harness straps in the slots an inch above your baby's shoulders." 31. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus ß-hemolytic infection. Which of the following medications should the nurse plan to administer? Ampicillin Azithromycin Ceftriaxone Acyclovir 32. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider? WBC count 11,000/mm3 Hgb 11.2 g/dL Hct 34% Platelets 140,000/m 33. A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full-term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client's obstetrical history as which of the following? Gravida 3, Para 2 Gravida 3, Para 3 Gravida 4, Para 2 Gravida 4, Para 3 34. A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first? Elevate the client's legs to a 30° angle. Insert an indwelling urinary catheter. Massage the client's fundus. Initiate an infusion of oxytocin. 35. A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first? Change the client's position. Palpate the uterus to assess for tachysystole. Increase the client's IV infusion rate. Administer oxygen at 10 L/min via nonrebreather mask. 36. A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility? Premature ovarian failure Renal calculi Dysmenorrhea Recurrent urinary tract infection 37. A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer? Digoxin Calcium gluconate Vitamin B6 Propranolol 38. A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make? "You will receive a medication through an IV for this test." "You should expect the test to take about 30 minutes." "You should not eat or drink for 4 hours prior to the test." "This test will help determine if your baby's lungs are mature." 39. A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output? Bradycardia Flushed face Hypotension Polyuria 40. A nurse is caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication? (Select all that apply.) "Are you taking over-the-counter medications?" "Do you have a history of gastric problems?" "What kind of contraception will you be using?" "Are you being treated for high blood pressure?" "Do you have a history of cataracts?" 41. A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.) Instruct the client to wash their hands prior to breastfeeding. Teach the client about proper latching-on techniques. Encourage the client to alternate breastfeeding with formula feeding. Instruct the client to avoid using a breast pump. Encourage the client to allow their nipples to air dry after feedings 42. A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for administration of this medication? Heart disease Cervical dilation of 2 cm Gestational age of 34 weeks Allergy to penicillin 43. A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicate an understanding of the teaching? "I will leave the diaphragm in place for 4 hours following intercourse." "I will remove the diaphragm by catching the rim below the dome with my forenger." "I will place a thin layer of mineral oil on the diaphragm once per week." "I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it." 44. A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching? "A yearly Pap test is recommended until 70 years of age." "Pap tests are discontinued following removal of the ovaries." "Avoid having sexual intercourse for 24 hours prior to the Pap test." "Viral infections can be detected by a Pap test." 45. A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR? Fetal hypoxemia Cord compression Uteroplacental insuciency Head compression 46. A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? Hypertonia Jitteriness Acrocyanosis Generalized petechiae 47. A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include? Check the newborn's temperature every 8 hr. Apply moisturizing lotion to the newborn's skin every 4 hr. Give the newborn 1 oz of glucose water every 4 hr. Reposition the newborn every 2 to 3 hr. 48. A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include? "Retract the foreskin until you feel resistance." "Use a cotton swab to clean under the foreskin." "Apply petroleum jelly to the foreskin." "Wash the penis once per day with soap and water." 49. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first? A client who gave birth 1 day ago and needs Rho(D) immune globulin A client who gave birth 3 days ago and reports breast fullness A client who gave birth 12 hr ago and reports an increase in urinary output A client who gave birth 8 hr ago and is saturating a perineal pad every hour