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
... [Show More] 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 [Show Less]