DTRs should be... +2
From gestational weeks to , the fundal height is approximately equal to the number
18, 32; 2
of weeks of gestation plus or minus cm.
T/F: A client must be NPO before completing a NST False; there's no indication and hydration is encouraged
What position should the patient be in for a NST? Semi-Fowler's and tilted either to the right or left.
T/F: Massaging the abdomen does not stimulate fetal movement True
T/F: During a NST, the nurse should instruct the patient to press a button each time fetal
True; it is provided; movement may not be evident on tracing or FHR monitor
movement is detected.
Hypoglycemia Consistent Findings Decreased temperature, poor feeding, respiratory distress and lethargy.
Hyperbilirubinemia Consistent Findings Yellow sclera and oral mucosa, poor feeding
T/F: Newborn is not at an increased risk for hyperbilirubinemia if they have ecchymotic caput
False; the NB is at a higher risk of hyperbilirubinemia
succadeneum
Decreased temperature, yellow sclera and oral mucosa, poor feeding, respiratory distress &
Sepsis Consistent Findings
lethargy
Expected Newborn Respiratory Rate 30 to 60 bpm
Expected Newborn Oxygen Saturation Greater than 94%
Expected Newborn Temperature 97.7 to 99.5 F
Inconsolability, high-pitched cry, increased muscle tone, tremors (severe), hyperactive Moro
Manifestations of Newborn Abstinence Syndrome (NAS)
reflex, excessive pacifier sucking, poor feeding & loose stools
Risk Factor for Newborn Abstinence Syndrome Maternal history of methadone use during pregnancy
Laboratory Findings of Newborn Abstinence Syndrome Maternal and newborn urine toxicology screen positive for opiates
T/F: Parents should begin passive ROM exercises on the newborn's attected arm after 2 weeks False; exercises should begin after 1 week to restore function of the extremity.
T/F: The nurse should assess for the grasp reflex in the newborn's attected extremity True
T/F: The nurse should immobilize the attected arm (Erb's paralysis or brachial plexus injury)
True; the nurse should do this intermittently.
of the newborn across the abdomen by pinning the newborn's sleeve to their shirt.
T/F: Parents should limit physical handling of a newborn with a Brachial injury or Erb's
False; this is contraindicated as it decreases bonding between the NB and parents.
paralysis for 2 weeks.
Absent Moro reflex in the arm (arm remains at the side of the NB), internally rotated and
abducted shoulder and arm, extended elbow, pronation of the forearm, along with flexed
wrist and fingers, & no spontaneous movement of arm.
Manifestations of Erb-Duchenne Paralysis
T/F: Only the upper portion of the arm is attected in Erb-Duchenne paralysis True
T/F: The function of the wrists and fingers are attected with Erb-Duchenne paralysis False; the function is not attected.
Low temperature or temperature below the expected range, RR above the expected range &
Manifestations of Newborn Cold Stress
hypoglycemia
Blood glucose levels and temperature
1/5
, & are parameters that should be monitored during cold stress in a
newborn.
T/F: The nurse should obtain a prescription for an ABG when a Newborn has cold stress. True; the NB is at risk of developing metabolic acidosis.
T/F: A BP of 130/70 or 138/68 in a pregnant woman is a cause of concern. False; slightly elevated readings should be monitored but are not concerning.
Popliteal angle of 90 degrees, creases over the entire foot sole, and raised areolas with 3 to
Signs of Newborn Maturity According to the New Ballard Score
4mm buds
Signs of Newborn Immaturity According to the New Ballard Score Minimal arm recoil and decreased muscular tone
1,000mg = 1g
Braxton Hicks contractions, swelling of the feet and ankles at the end of the day, & SOB when
Expected Manifestations in the Third Trimester
climbing the stairs.
False; this is a contraindication because it prolongs clotting time and can increase bleeding
T/F: The nurse should administer aspirin to a patient with Thrombophlebitis
risk.
T/F: The nurse should not massage the attected leg every 12 hours of a patient with Throm-
True; it can dislodge the clot and cause pulmonary embolism
bophlebitis.
T/F: The nurse should apply a warm compress to the calf of a patient with Thrombophlebitis True; this promotes circulation and decreases edema; cold would be a contraindication.
T/F: The nurse should elevate the attected leg of a patient who has Thrombophlebitis True; relieves pain and promotes circulation.
T/F: Abdominal cramping in the first trimester does not indicate ectopic pregnancy or spon-
False; it does, and patient would be a priority to the provider
taneous abortion
T/F: Flaccid uterus is an indication for the administration of Oxytocin True
T/F: Oxytocin increases contractility of the uterus and enhances contractions. True
T/F: Excess vaginal bleeding is not an indication for the administration of Oxytocin False; enhanced contractility of the uterus helps with this
T/F: Cessation of uterine dilation is not an indication for the administration of Oxytocin False
T/F: Prolonged active labor is an indication for the administration of Oxytocin True
1. Palpate the fundus to identify the fetal part.
2. Determine the location of the fetal back.
Leopold's Maneuver Steps in Order
3. Palpate for the fetal part presenting at the inlet.
4. Palpate the cephalic prominence to identify the attitude of the head.
T/F: The nurse feeds the newborn water or glucose water prior to phototherapy False; the NB is breastfed or formula-fed
T/F: The nurse should discontinue phototherapy if the newborn develops a rash (fine). False; this is expected and temporary; requires no treatment
Simethicone Use Reduces bloating, discomfort, or pain caused by excessive gas
T/F: Leakage of fluid from the vagina (leukorrhea) is a expected and normal after an amnio-
False; indicates a potential complication r/t amniotic fluid
centesis
SSRI Withdrawal Manifestation of a Newborn Vomiting
LGA, hyperglycemia, bradypnea, irritability, agitation, tremors, diarrhea, vomiting; typically
Expected manifestations associated with fetal exposure to SSRIs
lasts for 2 days
T/F: Levonorgestrel (Plan B) has no ettect on other oral contraceptives True
T/F: Women should be evaluated for pregnancy if menstruation does not occur within 3 days
False; 7 days or one week
following administration of Levonorgestrel (Plan B).
T/F: Late decelerations are a contraindication for oxytocin True; indicative of uteroplacental insuflciency which is also a CI
Abdominal pain (acute or chronic lower abdomen pain), green-yellow discharge & pain or
Consistent Findings of Gonorrhea
urination (dysuria)
2/5
From gestational weeks to , the fundal height is approximately equal to the number
18, 32; 2
of weeks of gestation plus or minus cm.
T/F: A client must be NPO before completing a NST False; there's no indication and hydration is encouraged
What position should the patient be in for a NST? Semi-Fowler's and tilted either to the right or left.
T/F: Massaging the abdomen does not stimulate fetal movement True
T/F: During a NST, the nurse should instruct the patient to press a button each time fetal
True; it is provided; movement may not be evident on tracing or FHR monitor
movement is detected.
Hypoglycemia Consistent Findings Decreased temperature, poor feeding, respiratory distress and lethargy.
Hyperbilirubinemia Consistent Findings Yellow sclera and oral mucosa, poor feeding
T/F: Newborn is not at an increased risk for hyperbilirubinemia if they have ecchymotic caput
False; the NB is at a higher risk of hyperbilirubinemia
succadeneum
Decreased temperature, yellow sclera and oral mucosa, poor feeding, respiratory distress &
Sepsis Consistent Findings
lethargy
Expected Newborn Respiratory Rate 30 to 60 bpm
Expected Newborn Oxygen Saturation Greater than 94%
Expected Newborn Temperature 97.7 to 99.5 F
Inconsolability, high-pitched cry, increased muscle tone, tremors (severe), hyperactive Moro
Manifestations of Newborn Abstinence Syndrome (NAS)
reflex, excessive pacifier sucking, poor feeding & loose stools
Risk Factor for Newborn Abstinence Syndrome Maternal history of methadone use during pregnancy
Laboratory Findings of Newborn Abstinence Syndrome Maternal and newborn urine toxicology screen positive for opiates
T/F: Parents should begin passive ROM exercises on the newborn's attected arm after 2 weeks False; exercises should begin after 1 week to restore function of the extremity.
T/F: The nurse should assess for the grasp reflex in the newborn's attected extremity True
T/F: The nurse should immobilize the attected arm (Erb's paralysis or brachial plexus injury)
True; the nurse should do this intermittently.
of the newborn across the abdomen by pinning the newborn's sleeve to their shirt.
T/F: Parents should limit physical handling of a newborn with a Brachial injury or Erb's
False; this is contraindicated as it decreases bonding between the NB and parents.
paralysis for 2 weeks.
Absent Moro reflex in the arm (arm remains at the side of the NB), internally rotated and
abducted shoulder and arm, extended elbow, pronation of the forearm, along with flexed
wrist and fingers, & no spontaneous movement of arm.
Manifestations of Erb-Duchenne Paralysis
T/F: Only the upper portion of the arm is attected in Erb-Duchenne paralysis True
T/F: The function of the wrists and fingers are attected with Erb-Duchenne paralysis False; the function is not attected.
Low temperature or temperature below the expected range, RR above the expected range &
Manifestations of Newborn Cold Stress
hypoglycemia
Blood glucose levels and temperature
1/5
, & are parameters that should be monitored during cold stress in a
newborn.
T/F: The nurse should obtain a prescription for an ABG when a Newborn has cold stress. True; the NB is at risk of developing metabolic acidosis.
T/F: A BP of 130/70 or 138/68 in a pregnant woman is a cause of concern. False; slightly elevated readings should be monitored but are not concerning.
Popliteal angle of 90 degrees, creases over the entire foot sole, and raised areolas with 3 to
Signs of Newborn Maturity According to the New Ballard Score
4mm buds
Signs of Newborn Immaturity According to the New Ballard Score Minimal arm recoil and decreased muscular tone
1,000mg = 1g
Braxton Hicks contractions, swelling of the feet and ankles at the end of the day, & SOB when
Expected Manifestations in the Third Trimester
climbing the stairs.
False; this is a contraindication because it prolongs clotting time and can increase bleeding
T/F: The nurse should administer aspirin to a patient with Thrombophlebitis
risk.
T/F: The nurse should not massage the attected leg every 12 hours of a patient with Throm-
True; it can dislodge the clot and cause pulmonary embolism
bophlebitis.
T/F: The nurse should apply a warm compress to the calf of a patient with Thrombophlebitis True; this promotes circulation and decreases edema; cold would be a contraindication.
T/F: The nurse should elevate the attected leg of a patient who has Thrombophlebitis True; relieves pain and promotes circulation.
T/F: Abdominal cramping in the first trimester does not indicate ectopic pregnancy or spon-
False; it does, and patient would be a priority to the provider
taneous abortion
T/F: Flaccid uterus is an indication for the administration of Oxytocin True
T/F: Oxytocin increases contractility of the uterus and enhances contractions. True
T/F: Excess vaginal bleeding is not an indication for the administration of Oxytocin False; enhanced contractility of the uterus helps with this
T/F: Cessation of uterine dilation is not an indication for the administration of Oxytocin False
T/F: Prolonged active labor is an indication for the administration of Oxytocin True
1. Palpate the fundus to identify the fetal part.
2. Determine the location of the fetal back.
Leopold's Maneuver Steps in Order
3. Palpate for the fetal part presenting at the inlet.
4. Palpate the cephalic prominence to identify the attitude of the head.
T/F: The nurse feeds the newborn water or glucose water prior to phototherapy False; the NB is breastfed or formula-fed
T/F: The nurse should discontinue phototherapy if the newborn develops a rash (fine). False; this is expected and temporary; requires no treatment
Simethicone Use Reduces bloating, discomfort, or pain caused by excessive gas
T/F: Leakage of fluid from the vagina (leukorrhea) is a expected and normal after an amnio-
False; indicates a potential complication r/t amniotic fluid
centesis
SSRI Withdrawal Manifestation of a Newborn Vomiting
LGA, hyperglycemia, bradypnea, irritability, agitation, tremors, diarrhea, vomiting; typically
Expected manifestations associated with fetal exposure to SSRIs
lasts for 2 days
T/F: Levonorgestrel (Plan B) has no ettect on other oral contraceptives True
T/F: Women should be evaluated for pregnancy if menstruation does not occur within 3 days
False; 7 days or one week
following administration of Levonorgestrel (Plan B).
T/F: Late decelerations are a contraindication for oxytocin True; indicative of uteroplacental insuflciency which is also a CI
Abdominal pain (acute or chronic lower abdomen pain), green-yellow discharge & pain or
Consistent Findings of Gonorrhea
urination (dysuria)
2/5
