Maternal Newborn Practice A Assessment

Maternal Newborn Practice A Assessment 1. A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client’s medical record, which of the following findings should the nurse report the provider? BP: 130/78 RR: 20 HR: 90 Hemoglobin: 12 Hematocrit: 34% 1-hr glucose tolerance test: 120 Fundal height: 30 cm, good fetal movement, not experiencing headache, dizziness, blurred vision, or vaginal bleeding, FHR: 110 a. Answer: Fundal height measurement b. Why?: Fundal height should be in CM and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. c. A positive 1 hr glucose tolerance test is from 130 to 140 mg/dL or greater d. Hematocrit should be greater than 33% e. Normal fetal heart rate is between 110 to 160 2. A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? a. Answer: Respiratory Rate 10 breaths/min b. Why?: Report a respiratory rate less than 12 breaths/min to the HCP because this is a manifestation of magnesium toxicity. Have the antidote, calcium gluconate available. c. Nausea is an expected adverse effect and the nurse should reassure the client and provide comfort measures. d. Oliguria is a manifestation of magnesium toxicity and the nurse should report urinary output less than 25 to 30 ml/hr to the HCP. e. Flushing and feeling hot is an expected adverse effect of magnesium sulfate and the nurse should reassure and provide comfort measures. 3. A nurse is assessing a newborn 12 hours after birth. Which of the following manifestations should the nurse report the provider? a. Answer: Jaundice b. Why?: Jaundice occurring within the first 24 hours of birth is associated with ABO incompatibility, hemolysis, or Rh isoimmunization. c. Acrocyanosis is an expected finding 24 to 48 hrs after birth and is the bluish discoloration of the hands and feet d. Transient strabismus is a normal variation in the newborn’s eyes that can persist until the 3rd or 4th month of age. e. Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput. 4. A nurse is admitting a client to the labor and delivery unit when the client states, “My water just broke.” Which of the following interventions is the nurse’s priority? a. Answer: Begin FHR monitoring b. Why?: The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being.