Maternal newborn practice test B with rationale
A nurse is caring for a client who is at 35 of gestation and has placenta previa. Which of
the following actions should the nurse take? - Answer - Initiate continuous external fetal monitoring
The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring,
which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones? - Answer - Just above the symphysis pubis
At the end of the first trimester of pregnancy, the client's uterus is approximately the size
of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.
A nurse is teaching a client who is at 35 weeks gestation and has a -description for a nonstress test. Which of the following statements should the nurse include in the teaching? - Answer - You will be offered orange juice to drink during the test
A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results.
The nurse is reviewing the medical record of a newly admitted client who is at 32 weeks
of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring - Answer - Oligohydraminos
The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? - Answer - Cover the newborns eyes while under the therapy light
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? - Answer - Have calcium gluconate readily readily available The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.
The nurse is providing discharge teaching to the parents of a newborn about carseat safety. Which of the following instructions should the nurse include? - Answer - Place the retainer clip at the level of the newborns armpits
The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.e the retainer clip at the level of the newborns armpits
A school nurse is providing teaching to a adolescent about levonorgestrel contraception.
Which of the following information should the nurse include in the teaching? - Answer - You should take the medication within 72 hours of having unprotected sex
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as
possible within 72 hr after unprotected sexual intercourse.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? - Answer - Massage the clients fundus The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? - Answer - Swelling of the face
swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.lling of the face
A nurse is caring for a client who is in labor and who's fetus is in the right occiput posterior position. The client is dilated to 8cm and is reporting back pain. Which of the following actions should the nurse take? - Answer - Apply sacral counterpressure
The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.
A nurse is caring for a client who is at 35 of gestation and has placenta previa. Which of
the following actions should the nurse take? - Answer - Initiate continuous external fetal monitoring
The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring,
which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones? - Answer - Just above the symphysis pubis
At the end of the first trimester of pregnancy, the client's uterus is approximately the size
of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.
A nurse is teaching a client who is at 35 weeks gestation and has a -description for a nonstress test. Which of the following statements should the nurse include in the teaching? - Answer - You will be offered orange juice to drink during the test
A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results.
The nurse is reviewing the medical record of a newly admitted client who is at 32 weeks
of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring - Answer - Oligohydraminos
The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? - Answer - Cover the newborns eyes while under the therapy light
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? - Answer - Have calcium gluconate readily readily available The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.
The nurse is providing discharge teaching to the parents of a newborn about carseat safety. Which of the following instructions should the nurse include? - Answer - Place the retainer clip at the level of the newborns armpits
The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.e the retainer clip at the level of the newborns armpits
A school nurse is providing teaching to a adolescent about levonorgestrel contraception.
Which of the following information should the nurse include in the teaching? - Answer - You should take the medication within 72 hours of having unprotected sex
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as
possible within 72 hr after unprotected sexual intercourse.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? - Answer - Massage the clients fundus The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? - Answer - Swelling of the face
swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.lling of the face
A nurse is caring for a client who is in labor and who's fetus is in the right occiput posterior position. The client is dilated to 8cm and is reporting back pain. Which of the following actions should the nurse take? - Answer - Apply sacral counterpressure
The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.
