RN Maternal Newborn
01. A nurse on the postpartum unit is caring for a client following a cesarean birth.
Which of the following assessments is the nurse's priority?
Amount of lochia
When using the airway, breathing, circulation approach to client care, the nurse
should place the priority in the immediate postpartum period on assessing the
amount of postpartum lochia. The greatest risk to the client is bleeding and
postpartum hemorrhage.
02. A nurse is caring for a client who is in labor and whose fetus is in the right
occiput posterior position. The client is dilated to 8 cm and reports back pain.
Which of the following actions should the nurse take?
Apply sacral counterpressure
The nurse should apply sacral counterpressure to assist in relieving back labor pain
related to fetal posterior position.
03. A nurse is demonstrating to a client how to bathe her newborn. In which order
should the nurse perform the following actions? (Move the steps into the box on
the right, placing them in the selected order of performance. Use all the steps.)
Wipe the newborn’s eyes from the inner canthus outward.
Wash the newborn’s neck by lifting the newborn’s chin.
Cleanse the skin around the newborn’s umbilical cord stump.
Wash the newborn’s legs and feet.
Clean the newborn’s diaper area.
The nurse should demonstrate how to bathe a newborn by using a head to toe,
clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes
from the inner canthus outward using plain water. The nurse should then wash the
newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the
skin around the umbilical cord stump followed by washing the newborn's legs and
feet. The last step of the bath should be to clean the newborn's diaper area.
04. A nurse is caring for a client and her partner who have experienced a fetal
death. Which of the following actions should the nurse take?
Take photos of the newborn to give to the parents.
The nurse should create a memory box that includes mementos of the newborn (for
, example, photos, the newborn's ID bands, the newborn's hat, and the newborn's
blanket).
05. A nurse is caring for a client who is at 36 weeks of gestation and has a positive
contraction stress test. The nurse should plan to prepare the client for which of the
following diagnostic tests?
Biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is
necessary. A biophysical profile will provide further evaluation with real-time
ultrasound.
06. A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to
the provider?
Platelets 50,000/mm3
A platelet count of 50,000/mm3 is below the expected reference range, which can
indicate disseminated intravascular coagulation. The nurse should report this result
to the provider.
07. A nurse is assessing a newborn who was born at 26 weeks of gestation using
the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil
The nurse should expect a newborn who was born at 26 weeks of gestation to have
decreased muscular tone, or minimal arm recoil.
08. A nurse is assessing a newborn following a circumcision. Which of the
following findings should the nurse identify as an indication that the newborn is
experiencing pain?
Chin quivering
Behavioral responses to a newborn's pain include facial expressions (for example,
chin quivering, grimacing, and furrowing of the brow).
09. A nurse is assessing the newborn of a client who took a selective serotonin
reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations
should the nurse identify as an indication of withdrawal from an SSRI?
01. A nurse on the postpartum unit is caring for a client following a cesarean birth.
Which of the following assessments is the nurse's priority?
Amount of lochia
When using the airway, breathing, circulation approach to client care, the nurse
should place the priority in the immediate postpartum period on assessing the
amount of postpartum lochia. The greatest risk to the client is bleeding and
postpartum hemorrhage.
02. A nurse is caring for a client who is in labor and whose fetus is in the right
occiput posterior position. The client is dilated to 8 cm and reports back pain.
Which of the following actions should the nurse take?
Apply sacral counterpressure
The nurse should apply sacral counterpressure to assist in relieving back labor pain
related to fetal posterior position.
03. A nurse is demonstrating to a client how to bathe her newborn. In which order
should the nurse perform the following actions? (Move the steps into the box on
the right, placing them in the selected order of performance. Use all the steps.)
Wipe the newborn’s eyes from the inner canthus outward.
Wash the newborn’s neck by lifting the newborn’s chin.
Cleanse the skin around the newborn’s umbilical cord stump.
Wash the newborn’s legs and feet.
Clean the newborn’s diaper area.
The nurse should demonstrate how to bathe a newborn by using a head to toe,
clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes
from the inner canthus outward using plain water. The nurse should then wash the
newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the
skin around the umbilical cord stump followed by washing the newborn's legs and
feet. The last step of the bath should be to clean the newborn's diaper area.
04. A nurse is caring for a client and her partner who have experienced a fetal
death. Which of the following actions should the nurse take?
Take photos of the newborn to give to the parents.
The nurse should create a memory box that includes mementos of the newborn (for
, example, photos, the newborn's ID bands, the newborn's hat, and the newborn's
blanket).
05. A nurse is caring for a client who is at 36 weeks of gestation and has a positive
contraction stress test. The nurse should plan to prepare the client for which of the
following diagnostic tests?
Biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is
necessary. A biophysical profile will provide further evaluation with real-time
ultrasound.
06. A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to
the provider?
Platelets 50,000/mm3
A platelet count of 50,000/mm3 is below the expected reference range, which can
indicate disseminated intravascular coagulation. The nurse should report this result
to the provider.
07. A nurse is assessing a newborn who was born at 26 weeks of gestation using
the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil
The nurse should expect a newborn who was born at 26 weeks of gestation to have
decreased muscular tone, or minimal arm recoil.
08. A nurse is assessing a newborn following a circumcision. Which of the
following findings should the nurse identify as an indication that the newborn is
experiencing pain?
Chin quivering
Behavioral responses to a newborn's pain include facial expressions (for example,
chin quivering, grimacing, and furrowing of the brow).
09. A nurse is assessing the newborn of a client who took a selective serotonin
reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations
should the nurse identify as an indication of withdrawal from an SSRI?
