Maternal Newborn
1. A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old newborn. Which of the following statements
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"I will wipe the colostrum off my nipple before my baby feeds."
Colostrum contains immunoglobulins, which provide passive immunity to the newborn. Colostrum also facilitates the newborn's passage of meconium. Therefore, the client should not remove the colostrum from her nipple prior to breastfeeding.
"I should wake up my baby to feed during the night."
Parents should awaken the newborn to feed every 4 hr at night for the first 24 to 48 hr after birth. Once the newborn is gaining weight, adequately progressing to demand feedings is safe.
"Since I am breastfeeding, I won't need to give my baby iron supplements until he's a year old."
After 6 months of age, all infants need to ingest iron-fortified cereal and other foods rich in iron.
"I should start to pump my breasts after each feeding when I get home."
Pumping after breastfeeding can lead to an oversupply of breast milk. The client should use the breast pump if the newborn is not able to feed at the breast. After breastfeeding is well-established, the client can pump intermittently to establish a reserve supply of breast milk if desired.
2. A nurse is collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider?
Tinnitus
Tinnitus is not an indication of magnesium toxicity and not a finding associated with preeclampsia.
Proteinuria 3+
Proteinuria 3+ is an indication of preeclampsia rather than magnesium toxicity.
Increased urine output
Magnesium sulfate is normally excreted in the urine. Decreased urine output can lead to inadequate elimination of the medication, which can result in magnesium toxicity.
Respiratory rate 10/min
Respiratory depression is an indication of magnesium toxicity. The nurse should report this finding to the provider.
3. A nurse is collecting data from a client who is at 37 weeks of gestation. Which of the following findings should the nurse report to the provider?
Leukorrhea
The nurse should identify that leukorrhea, or vaginal discharge, is an expected finding during pregnancy.
Nonpitting ankle edema
The nurse should identify that nonpitting ankle edema is an expected finding during the third trimester of pregnancy.
Tingling in fingers
The nurse should identify that tingling in fingers is an expected finding during pregnancy due to traction on the brachial plexus nerves.
Blurred vision
The nurse should identify that blurred vision or double vision are manifestations of gestational hypertension or preeclampsia. The nurse should report this finding to the provider.
4. A nurse is reviewing the medical record of a client who is at 26 weeks of gestation. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
Rheumatoid arthritis
The nurse should identify that connective tissue diseases, such as rheumatoid arthritis and systemic lupus erythematosus, increase a client's risk for preeclampsia.
BMI of 24
The nurse should identify that obesity, or a BMI greater than 30, increases a client's risk for preeclampsia. Other risk factors include multifetal gestation, infection, and chronic hypertension.
Iron-deficiency anemia
The nurse should identify that iron-deficiency anemia does not increase the client's risk for preeclampsia. Risk factors include multifetal gestation, infection, and chronic hypertension.
Oligohydramnios
The nurse should identify that oligohydramnios, or less than 300 mL of amniotic fluid, does not increase the client's risk for preeclampsia. Risk factors include multifetal gestation, infection, and chronic hypertension.
5. A nurse is reinforcing teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will place the baby's car seat in a rear-facing position until she is 1 year old."
The guardian should position the newborn's car seat rear-facing in the middle of the back seat until she is 2 years old, or as long as she meets the height and weight restrictions set by the car seat's manufacturer.
"I will position the retainer clip at the level of the baby's armpits."
The guardian should position the retainer clip at the level of the newborn's axillae and not over the neck or abdomen.
"I will place the shoulder harness straps in a slot 2 inches above the baby's shoulders."
The guardian should place the shoulder harness straps in the slots at or below the level of the newborn's shoulders.
"I will position the baby at a 60-degree angle in the car seat."
The guardian should position the newborn in the car seat at a 45° angle to prevent the newborn's head from fallin
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