TI 2023 & 2024 MATERNAL
NEWBORN TEST A AND B
Newborn delivered by repeat cesarean birth at 40 weeks of
gestation.
Birth weight 3,515 g (7 lb 12
... [Show More] oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Which should the Nurse report?
Respiratory findings
Temperature
Oxygen saturation
Central nervous system findings
Gastrointestinal findings - CORRECT ANSWER-Gastrointestinal
findings
Central nervous system findings
Client reports a small amount of bright red blood in their
underwear upon awakening. Client denies contractions or
abdominal pain.
External fetal monitor applied.
Potential Nursing Action
Indicated or Contraindicated
Assess cervical dilation
Weigh perineal pads.
Administer methotrexate.
Insert a large bore intravenous catheter. - CORRECT ANSWERContraindicated
Assess Cervical Dilation - She's currently bleeding and not in the
middle of labor, unnecessary.
Administer Methotrexate - She isn't having an ectopic pregnancy
- this is used to resolve ectopic pregnancies in the first trimester.
Indicated
Weigh Perineal Pads - We need to know how much blood she's
losing.
Insert a large bore IV - Third Trimester Bleeding may lead to
larger hemorrhage - having IV access is critical if we need to
administer fluids.
A nurse is assessing the newborn of a client who took selective
serotonin reuptake inhibitor during pregnancy. Which of the
following manifestations should the nurse identify as an
indication of withdrawal from an SSRI? - CORRECT ANSWERVomiting - Also could be irritability, agitation, tremors, or
diarrhea. These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who
request an oral
contraceptive. Which of the following findings in the clients
history show the nurse
recognized as a contraindication to oral contraceptives. select
all that apply
Cholecystitis
Hypertension
Human papillomavirus
Migraine headaches
Anxiety disorder - CORRECT ANSWER-Cholecystitis
Hypertension
Anxiety disorder
A nurse is caring for a newborn.Medical History
1600:Apgar Score 9 at 1 min and 9 at 5 min
Birth weight 10 lb 6 oz (4706 gm)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. - CORRECT
ANSWER-Indicated:
Educate the parents to begin ROM exercises on the affected arm
after 1 week. - ROM help restore functionality. Delay 1 week to
prevent additional injury to brachial plexus.
Assess for grasp reflex in the affected extremity. - With Erb's
Palsy (Erb-Duchenne) only the upper arm is affected. Wrist and
finger function should NOT be affected.
Immobilize the arm across the abdomen by pinning the
newborn's sleeve to their shirt. - This will assist int he healing
process.
A nurse is admitting a client to the labor and delivery unit when
the client states, "my water just broke", which of the following is
the priority intervention for the nurse to take? - CORRECT
ANSWER-Begin FHR Monitoring - The greatest risk to the client
and their fetus following a rupture of membranes is an umbilical
cord prolapse. FHR is the PRIORITY action.
A nurse in an antepartum clinic is providing care for a client who
is at 26 weeks gestation. Upon reviewing the clients medical
record, what findings should the nurse report to the provider?
1-hr Glucose of 130 to 140 (or greater) indicates a positive test.
Hematocrit of 34% is within range - should be greater than 33%.
FHR - Should be between 110/min to 160/min for a client at 26
weeks of gestation. - CORRECT ANSWER-Fundal height 30 cm -
Fundal height should be PLUS or MINUS 2cm from weeks of
gestation
A nurse is caring for a newborn who is 48 hr old.
Apgars: 7 at 1 min and 8 at 5 min of age
Birth weight: 3,515 g (7 lb 12 oz)
Maternal blood type: O+
Uncomplicated pregnancy.
Maternal use of marijuana during pregnancy
Client who gave birth plans to breastfeed.
Day 2, 0900:
Newborn awake, alert, and crying. Loosely<<<< wrapped in one
blanket. Mild tremors noted. Yellow discoloration of mucus
membranes and sclera noted. Respirations 88/min, no
retractions, grunting, or nasal flaring noted. Diaper changed for
small amount of urine and transitional stool.
Day 2, 0915:Blood glucose: 38 mg/dL (expected value greater
than 40 to 45 gm/dL
Potential Condition? - It's NOT NAS since Mom wasn't on opiates.
It's NOT Bilirubin issues so no phototherapy. None of the babies
S/S point to Respiratory distress either.
COLD STRESS
Encourage parent to breastfeed
Place newborn skin to skin on birthing parents chest.
Temperature - CORRECT ANSWERNurse is caring for a client who is at 22 weeks of gestation and is
HIV positive. Which of the following actions should the Nurse
take?
Administer Penicillin g2.4 million units - No, this should be done
for syphilis.
Instruct Client to schedule annual pelvic examination - NO -
should be every 6 months.
Tell the client they'll start medication for HIV immediately after
delivery. NO - It will begin DURING the prenatal AND perinatal
periods to decrease the risk of transmission to the newborn.
Report the client's condition to the local health department. YES -
HIV is one of the conditions that is REQUIRED to be reported. -
CORRECT ANSWER-Report the client's condition to the local
health department.
A nurse is reviewing the laboratory results for a client who is at
10 weeks gestation which of the following laboratory findings
should the nurse report to the provider?
Hemoglobin 10g/dL YES - this is below the 11 g/dL minimum for
pregnant women.
WBC Count - 15,000 - NO - normal is 5-15k during pregnancy
RBC 5.8million/mm3 - NO Within range of 5-6.25million for
pregnancy.
Hematocrit 34% - NO - greater than 33% is fine. - CORRECT
ANSWER-Hemoglobin 10g/dL
A nurse is assessing a 16 hr old newborn. Which of the findings
should the nurse report to the provider?
Substernal Retractions - This, alongside apnea, grunting, nasal
flaring, and tachypnea are manifestations of neonatal infection
OR respiratory distress in newborns and should be reported
IMMEDIATELY.
Acrocyanosis - Expected finding for the first 24 hours of birth,
this is the blueish hue/tinge to extremities.
Overlapping Suture Lines - This is an expected finding.
Head Circumference - 33cm/13in. - WITHIN RANGE - CORRECT
ANSWER-Substernal Retractions
A Nurse is assessing a late preterm newborn. Which of the
following mainfestations is an indication of hypoglycemia?
Hypertonia - NO - HYPOtonia.
Increased Feedings - NO - Low blood sugar newborns will exhibit
POOR feeding behaviors.
Hyperthermia - NO - They will have HYPOthermia.
Respiratory Distress - YES - Alongside jitteriness, lethargy, poor
feeding, apnea, seizures, and an abnormal cry. - CORRECT
ANSWER-Respiratory distress.
A nurse is assessing a client who gave birth vaginally 12 hours
ago and palpate her uterus to the right above the umbilicus.
Which of the following intervention should the nurse perform? [Show Less]