Assessment A Maternal Newborn
A nurse is collecting data from a client who is at 33 weeks gestation. Which of the
following findings should the nurse identify as an indication of a potential complication of
pregnancy? - answer epigastric pain
A nurse is reinforcing teaching about interventions to treat breast engorgement with a
client who is breastfeeding. Which of the following instructions should the nurse include
in the teaching? - answer Breastfeed the newborn at least every 2 hours
A nurse is assisting with collecting data from a newborn who was born 2 hours ago and
has respiratory distress. Which of the following findings should the nurse report to the
provider? - answer tachypnea
nasal flaring
retractions
expiratory grunting
A nurse is caring for a client during the postpartum period. Which of the following
findings should the nurse expect during the first 24 hr following delivery? - answer
Diuresis
Discharge of clear,yellow fluid from the breasts
Lower abdominal cramping
A nurse is reinforcing teaching with a new parent about the prevention of newborn
abduction. Which of the following statements by the parent indicates an understanding
of the teaching? - answer "I will ask the nurse to take care of my baby in the nursery if I
need to take a nap."
A nurse is reinforcing teaching about formula feeding a newborn with a group of new
parents. Which of the following instructions should the nurse include? - answer Allow
20-30 min for feedings.
A nurse is caring for a client who has received methylergonovine. Which of the following
should the nurse identify and document as an adverse effect of the medication? -
answer hypertension
A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The
newborn's grandfather asks if he may take the newborn to his daughter's room. Which
of the following responses should the nurse make? - answer "Let me wash my hands
and then I'll take your grandson to his mother."
A nurse is caring for a newborn who is receiving phototherapy. Which of the following
actions should the nurse take? - answer Place an opaque mask over the newborn's
eyes.
A nurse is planning to administer phytonadione (Vitamin K) to a newborn. Which of the
following actions should the nurse take? - answer Use the vastus lateralis as the
injection site.
, Assessment A Maternal Newborn
A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following
should the nurse report to the provider? - answer Perineal pad soaked in 15 min
A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse report to the provider? -
answer Blurred vision.
A nurse is caring for a newborn who is large for gestational age and is jittery. Which of
the following actions should the nurse take first? - answer Check the newborn's blood
glucose level.
A nurse who is caring for a client who is pregnant and has a prescription for nifedipine.
Which of the following outcomes should the nurse expect from this medication? -
answer Cessation of uterine contractions
A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation.
Which of the following laboratory findings should the nurse report to the provider? -
answer Hematocrit 30%
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients
should the nurse recommend the provider see first? - answer A client who is 37 weeks
of gestation and reports a persistent headache.
A nurse is assisting with planning care for a client who is breastfeeding and has
mastitis. Which of the following recommendations should the nurse include? - answer
Instruct the client to apply warm compresses to the affected breast.
A nurse on a postpartum unit is assisting in the care of a client who is experiencing
hypovolemic shock. Which of the following actions should the nurse take? - answer
Insert an indwelling catheter
A nurse is discussing family planning with a client who is requesting information about
available contraceptive methods. Which of the following client statements indicates an
understanding of the teaching? - answer "I should use water-soluble lubricant when my
partner wears a condom."
A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has
a positive hepatitis B test result. Which of the following actions should the nurse take? -
answer Explain to the client that she will receive the hepatitis B immune globulin
immediately.
A nurse is caring for a client who is at 11 weeks of gestation and reports frequent
vomiting. Which of the following findings should the nurse identify as an indication that
the client has hyperemesis gravidarum? - answer Ketonuria
A nurse is collecting data from a client who is at 33 weeks gestation. Which of the
following findings should the nurse identify as an indication of a potential complication of
pregnancy? - answer epigastric pain
A nurse is reinforcing teaching about interventions to treat breast engorgement with a
client who is breastfeeding. Which of the following instructions should the nurse include
in the teaching? - answer Breastfeed the newborn at least every 2 hours
A nurse is assisting with collecting data from a newborn who was born 2 hours ago and
has respiratory distress. Which of the following findings should the nurse report to the
provider? - answer tachypnea
nasal flaring
retractions
expiratory grunting
A nurse is caring for a client during the postpartum period. Which of the following
findings should the nurse expect during the first 24 hr following delivery? - answer
Diuresis
Discharge of clear,yellow fluid from the breasts
Lower abdominal cramping
A nurse is reinforcing teaching with a new parent about the prevention of newborn
abduction. Which of the following statements by the parent indicates an understanding
of the teaching? - answer "I will ask the nurse to take care of my baby in the nursery if I
need to take a nap."
A nurse is reinforcing teaching about formula feeding a newborn with a group of new
parents. Which of the following instructions should the nurse include? - answer Allow
20-30 min for feedings.
A nurse is caring for a client who has received methylergonovine. Which of the following
should the nurse identify and document as an adverse effect of the medication? -
answer hypertension
A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The
newborn's grandfather asks if he may take the newborn to his daughter's room. Which
of the following responses should the nurse make? - answer "Let me wash my hands
and then I'll take your grandson to his mother."
A nurse is caring for a newborn who is receiving phototherapy. Which of the following
actions should the nurse take? - answer Place an opaque mask over the newborn's
eyes.
A nurse is planning to administer phytonadione (Vitamin K) to a newborn. Which of the
following actions should the nurse take? - answer Use the vastus lateralis as the
injection site.
, Assessment A Maternal Newborn
A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following
should the nurse report to the provider? - answer Perineal pad soaked in 15 min
A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse report to the provider? -
answer Blurred vision.
A nurse is caring for a newborn who is large for gestational age and is jittery. Which of
the following actions should the nurse take first? - answer Check the newborn's blood
glucose level.
A nurse who is caring for a client who is pregnant and has a prescription for nifedipine.
Which of the following outcomes should the nurse expect from this medication? -
answer Cessation of uterine contractions
A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation.
Which of the following laboratory findings should the nurse report to the provider? -
answer Hematocrit 30%
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients
should the nurse recommend the provider see first? - answer A client who is 37 weeks
of gestation and reports a persistent headache.
A nurse is assisting with planning care for a client who is breastfeeding and has
mastitis. Which of the following recommendations should the nurse include? - answer
Instruct the client to apply warm compresses to the affected breast.
A nurse on a postpartum unit is assisting in the care of a client who is experiencing
hypovolemic shock. Which of the following actions should the nurse take? - answer
Insert an indwelling catheter
A nurse is discussing family planning with a client who is requesting information about
available contraceptive methods. Which of the following client statements indicates an
understanding of the teaching? - answer "I should use water-soluble lubricant when my
partner wears a condom."
A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has
a positive hepatitis B test result. Which of the following actions should the nurse take? -
answer Explain to the client that she will receive the hepatitis B immune globulin
immediately.
A nurse is caring for a client who is at 11 weeks of gestation and reports frequent
vomiting. Which of the following findings should the nurse identify as an indication that
the client has hyperemesis gravidarum? - answer Ketonuria
