A nurse provided discharge teaching to new parents on how to care for their newborn
following circumcision. Which of the following statements by the
... [Show More] parents indicates the
need for further clarification?
Select one:
a. "I should not remove the yellow exudate on the end of the penis."
b. "I will clean his penis with each diaper change."
c. "The circumcision will heal completely within a couple of weeks."
d. "I can give him a tub bath in two days."
d. "I can give him a tub bath in two days."
The newborn should not be immersed in water until the circumcision has healed and
the umbilical cord has detached. The circumcision should heal within two weeks.
A nurse is discussing the use of condoms with a female client. Which of the following
statements by client represents a need for further teaching?
Select one:
a. "My partner will put the condom on while his penis is erect."
b. "I will remove the condom 30 minutes after intercourse."
c. "My partner should leave an empty space at the tip."
d. "I can use spermicidal gels or creams to increase effectiveness."
b. "I will remove the condom 30 minutes after intercourse."
To avoid any semen spillage onto the vulva or the vaginal area, the condom must be
removed the same time as the penis. To do that the condom rim should be held in
place while the penis is withdrawn from the vagina.
A client reports awaking from sleep by contractions that are occurring every five
minutes and lasting 30-40 seconds. Which of the following questions should the
nurse ask to assess for true labor versus false labor?
Select one:
a. "When did your contractions begin?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
c. "What happens to your contractions when you move about?"
d. "Have you felt fetal movement over the last 24 hours?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially
MATERNAL NEWBORN HEALTH PROMOTION AND MAINTAINANCE
QUIZ(ANSWERED) GRADED A
rupture of membranes. False labor is characterized by painless, irregular, and
intermittent contractions that decrease in frequency, duration, and intensity with
walking or position changes. Contractions are felt in the lower back or above the
umbilicus and often stop with comfort measures (like oral hydration). There is usually
no vaginal discharge with false labor.
False labor is characterized by painless, irregular, and intermittent contractions that
decrease in frequency, duration, and intensity with walking or position changes.
Telling the client to walk is not a correct response because it is an intervention rather
than an assessment question.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the
purpose of the test. Which of the following is the correct response?
Select one:
a. The purpose of the NST is to assess the fetal CNS.
b. The purpose of the NST helps to determine gestational age.
c. The purpose of the NST is to determine fetal lie.
d. The purpose of the NST is to determine fetal breathing.
a. The purpose of the NST is to assess the fetal CNS.
This is the primary purpose of a NST. The test monitors the response of the FHR to
fetal movement. This allows the nurse to assess the FHR in relationship to the fetal
movement
A client in the early postpartum period is talkative and enjoys recounting the details of
her labor and birth. The nurse recognizes that the behaviors must likely indicate
which of the following?
Select one:
a. The taking-hold phase of maternal psychosocial adaptation.
b. The taking-in phase of maternal postpartum adjustment.
c. Postpartum role transition.
d. Positive mother-infant bonding.
b. The taking-in phase of maternal postpartum adjustment.
The taking-in phase begins immediately following birth and lasts a few hours to a
couple of days. It is characterized by the mother being excited and talkative, reliving
her birthing experience, and focusing on her own needs and the overall health of her
newborn.
The taking-hold phase of maternal postpartum adjustment begins on the second to
third post-partum day and lasts 10 days to several weeks. The woman's focus is on
exerting her independence in competently caring for her newborn. She may verbalize
fears of incompetence or anxiety about exhaustion, and needs acceptance and
encouragement. Postpartum depression may occur during this time.
A nurse is positioning a client on the operating room table in preparation for a
cesarean birth. Which of the following is the correct position?
Select one:
a. Lithotomy position with a foam wedge behind the shoulders.
b. Supine position with foam wedge positioned under one hip. C
c. Modified Trendelenburg position with a foam wedge under the legs.
d. Left lateral position with a foam wedge between the legs.
b. Supine position with foam wedge positioned under one hip.
The supine position is appropriate for abdominal surgery (cesarean birth), and a
wedge under one hip laterally tilts the client and reduces uterine weight on the vena
cava and descending aorta. This helps maintain optimal perfusion of oxygenated
blood to the fetus during the procedure.
Upgrade to remove ads
Only $1/month
A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates
clinical manifestations of the condition. Which assessment finding is associate with
this condition?
Select one:
a. Negative Startle reflex
b. Hypothermia
c. Increased drowiness
d. Diminished tendon reflexes
b. Hypothermia
Thermal regulation issues are noted with this condition, such as hypothermia or
hyperthermia.
the neonate will demonstate increase wakefulness, sleep pattern disturbances and
shrilled high-pitched cries.
Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a
weak, high pitched cry. Which of the following would be the nurse's priority action?
Select one:
a. Hold and comfort the infant to stop the crying.
b. Feed the infant oral feeding.
c. Perform a heel stick to check serum glucose.
d. Obtain an order for a drug screening blood test.
c. Perform a heel stick to check serum glucose.
The priority action is to confirm the serum glucose before proceeding. A blood
glucose level less than 40-45 mg/dL by heel stick is an urgent situation requiring
therapy with glucose - generally orally.
A nurse is assessing a client during her first prenatal visit. The client reports that her
last normal period began on April 22. Use Nagele's rule to calculate this client's
expected date of birth (EDB). Use the MMDD format to enter exactly four numerals,
with no spaces or punctuation between the numbers.
Select one:
a. 0729
b. 0129
c. 0122
d. 0722
b. 0129
To use Nagele's rule subtract 3 months and add 7 days to the first day of the client's
last normal menstrual period.
A nurse is performing a fundal assessment on the client's second postpartum day.
Which of the following should the nurse expect if the client is experiencing normal
involution?
Select one:
a. The fundus will be one centimeter above the umbilicus.
b. The fundus will be two centimeters below the umbilicus.
c. The fundus will be one centimeter below the umbilicus.
d. The fundus will be at the level of the umbilicus.
c. The fundus will be one centimeter below the umbilicus.
The fundus descends 1-2 cms per day, so from the highest point of 1 cm above the
umbilicus at 12 hours, it should be 0 to 1 cms below the umbilicus on day two
A nurse is teaching a client the correct use a diaphragm as a method of
contraception. Which of the following statements is correct?
Select one:
a. Douche promptly after removing the diaphragm
b. Do not use any cream or jelly with the diaphragm
c. Insert diaphragm at least 8 hours prior to sexual intercourse
d. Leave diaphragm in place for at least 6 hours post coitus
d. Leave diaphragm in place for at least 6 hours post coitus
The diaphragm should be left in place for at least 6 hours post intercourse.
The client asks the nurse to explain the difference between true and false labor.
Which of the following is an example of true labor?
Select one:
a. In true labor the cervix will dilate and efface
b. In true labor walking will cause contractions to slow down
c. In true labor the presenting part is engaged
d. In true labor contractions are felt in the abdomen above the umbilicus
a. In true labor the cervix will dilate and efface
Progressive changes in dilation and effacement are the ultimate signs of true labor.
The nurse is observing sibling adaptation behaviors to the newborn infant during a
family visit. To facilitate sibling acceptance, which action by the parents can assist
with bonding?
Select one:
a. Provide the sibling a stuffed animal that they care for while the parents nurture the
newborn.
b. Discuss with the sibling the importance of being more independent.
c. Encourage the sibling to spend time primarily with the babysitter.
d. Create new traditions and routines.
a. Provide the sibling a stuffed animal that they care for while the parents nurture the
newborn.
this will help the sibling feel they are a part of the new family experience.
A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic
therapy. Several hours after the infusion was started, contractions ceased. Which of
the following is the best analysis of this data?
Select one:
a. The drug is having a therapeutic effect
b. The medication dose should be decreased
c. The medication dose should be increased
d. Deep tendon reflexes should be assessed
a. The drug is having a therapeutic effect
A cessation of labor is the desired therapeutic effect of a tocolytic.
A breastfeeding mother develops engorgement on her second postpartum day. Which
of the following statements by the client indicates a need for further teaching?
Select one:
a. I will apply warm packs to each breast prior to feeding.
b. I will offer my baby a bottle following each feeding.
c. I will feed my baby every 2 hours.
d. I will use a breast pump if my breasts do not soften.
b. I will offer my baby a bottle following each feeding.
Bottle feeding while breastfeeding could lead to nipple confusion and interfere with
successful breastfeeding. This mother needs further teaching.
For breast engorgement, apply cool compresses between feedings and apply warm
compresses or take a warm shower prior to breastfeeding.
A nurse is caring for a client who has been prescribed magnesium sulfate for
pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and
urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the
following symptoms should be reported to the provider?
Select one:
a. The client is voiding 40 mL/hr
b. The client reports feeling flushed and warm
c. The client is drowsy and difficult to rouse
d. The client's blood pressure is 130/70 mm Hg
c. The client is drowsy and difficult to rouse
If the client is sleepy and difficult to rouse she may be experiencing symptoms of
magnesium sulfate toxicity. This should be immediately reported to the provider.
A client who is 32 weeks pregnant presents to the emergency room with bright red
vaginal bleeding for the last 3 hours. The client reports feeling fetal movement since
the bleeding started. Which of the following is the nurse's priority action?
Select one:
a. Assess maternal vital signs
b. Assess fetal heart tones
c. Perform a vaginal exam
d. Administer a 500 mL fluid bolus
a. Assess maternal vital signs
Since the client is feeling the baby move the most important step would be to
establish baseline vital signs to determine potential blood loss and signs of shock.
A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The
neonate is presenting with a high pitched cry and jitteriness. Which of the following is
the nurse's priority intervention?
Select one:
a. Offer the neonate breast milk or formula
b. Place the neonate under a radiant warmer
c. Administer subcutaneous insulin
d. Provide oxygen via oxyhood
a. Offer the neonate breast milk or formula
A neonate of a diabetic mother is at risk for hypoglycemia. High glucose loads are
present in the infant in utero. When maternal blood glucose via the placenta abruptly
stops at birth, the neonate experiences a rapid drop in blood sugar. Signs of
hypoglycemia in the neonate are jitteriness, lethargy, poor muscle tone, apnea, high
pitched cry, and vomiting. Nursing interventions should focus on monitoring for sign of
complications associated with hypoglycemia.
A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an
appropriate psychological task for the client?
Select one:
a. Verbalize concerns about the health care facility
b. Accept the fact that she is pregnant
c. Begin to think about names for the baby
d. View morning sickness as tolerable
b. Accept the fact that she is pregnant
The developmental task during the first trimester is to accept the reality of the
pregnancy. Accepting the reality of being pregnant allows the client to see a provider
and get prenatal care.
A client diagnosed with pregnancy induced hypertension (PIH) has been receiving a
Magnesium Sulfate infusion for three days. Serum drug levels have been between 8-
10 mg/dl. Which of the following finding should the nurse expect to assess in the
infant after delivery?
Select one:
a. Lethargy and respiratory depression
b. Hypothermia and bradycardia
c. Tachycardia and respiratory distress
d. Hyperactivity and irritability
a. Lethargy and respiratory depression
Mag. Sulfate blocks Neuromuscular transmission and is a CNS depressant.
Therefore the infant will exhibit the same signs we assess for in a pregnant client
receiving Magnesium: lethargy and respiratory depression. Therapeutic levels of
Mag. Sulfate are 4-8mg/dl.
A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the
following risk factors is most important to the care of this client?
Select one:
a. Increased size of neonate's heart.
b. Maternal history of cytomegalovirus.
c. A decreased number of functional alveoli.
d. Documented birth trauma.
b. Maternal history of cytomegalovirus.
Cytomegalovirus can be transferred via the placenta directly onto the fetal circulatory
system and transmitted directly from infected amniotic fluid.
A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving
Magnesium Sulfate IV. Which of the following assessment findings is the first sign of
Magnesium toxicity?
Select one:
a. Respiratory depression
b. Nausea and vomiting
c. Decreased deep tendon reflexes
d. Visual blurring
c. Decreased deep tendon reflexes
Magnesium Sulfate reduces striated muscle contractions due to a depressant effect
on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate
include diminished tendon reflexes, hypotension and prolonged PR intervals. Later [Show Less]