TEST BANK MATERNAL-NEWBORN NURSING THE CRITICAL COMPONENTS OF NURSING CARE, 3RD EDITION, ROBERTA

TEST BANK MATERNAL-NEWBORN NURSING THE CRITICAL
COMPONENTS OF NURSING CARE, 3RD EDITION, ROBERTA

TEST BANK MATERNAL-NEWBORN
NURSING THE CRITICAL
COMPONENTS OF NURSING CARE, 3RD
EDITION, ROBERTA

, TEST BANK MATERNAL-NEWBORN NURSING THE CRITICAL
COMPONENTS OF NURSING CARE, 3RD EDITION, ROBERTA

1. A nurse is caring for a client who is in labor. Which of the
following findings should the nurse report to the provider?
o A. Contractions lasting 80 to 90 seconds
o B. Contraction interval of 2 to 3 minutes
o C. Fetal heart rate of 90 beats per minute
o D. Presence of bloody show
o Rationale: A fetal heart rate of 90 beats per minute indicates
bradycardia, which can be a sign of fetal distress and requires
immediate attention.
2. A client who is at 36 weeks of gestation is undergoing a
nonstress test (NST). The nurse observes two accelerations of
15 beats per minute lasting 15 seconds each over a 20-minute
period. How should the nurse interpret this finding?
o A. Nonreactive NST
o B. Reactive NST
o C. Unsatisfactory NST
o D. Positive NST
o Rationale: A reactive NST indicates fetal well-being, with
two accelerations of at least 15 beats per minute lasting at
least 15 seconds within a 20-minute period.
3. Which of the following interventions should a nurse implement
to prevent thrombophlebitis in a postpartum client?
o A. Encourage the client to drink plenty of fluids
o B. Instruct the client to wear compression stockings
o C. Encourage early ambulation
o D. Administer prophylactic antibiotics
o Rationale: Early ambulation helps prevent the formation of
blood clots by promoting circulation.
4. A nurse is assessing a newborn who is 5 minutes old. Which of
the following Apgar scores requires immediate intervention?
o A. 8
o B. 4
o C. 7
o D. 9

, TEST BANK MATERNAL-NEWBORN NURSING THE CRITICAL
COMPONENTS OF NURSING CARE, 3RD EDITION, ROBERTA

o Rationale: An Apgar score of 4 indicates moderate to severe
distress, requiring immediate resuscitation and intervention.
5. Which of the following is the priority action for a nurse caring
for a client experiencing postpartum hemorrhage?
o A. Massage the fundus
o B. Administer oxytocin
o C. Insert a urinary catheter
o D. Start an IV line
o Rationale: Massaging the fundus is the priority action to
stimulate uterine contractions and reduce bleeding.
6. A nurse is teaching a client about signs of true labor. Which of
the following should the nurse include?
o A. Regular contractions that increase in intensity
o B. Contractions relieved by walking
o C. No change in cervical dilation
o D. Discomfort primarily in the abdomen
o Rationale: True labor is characterized by regular
contractions that increase in intensity and cause cervical
dilation.
7. A nurse is caring for a client who is in the first stage of labor
and receiving an epidural. Which of the following actions
should the nurse take?
o A. Encourage the client to ambulate
o B. Monitor the client's blood pressure frequently
o C. Position the client in a supine position
o D. Assist the client to change position every hour
o Rationale: Changing the client's position every hour helps to
prevent complications and ensure proper epidural function.
8. A client who is breastfeeding asks the nurse how to know if the
newborn is getting enough milk. Which of the following
responses should the nurse make?
o A. "Your baby should nurse for 5 minutes on each breast."
o B. "Your baby should have 6 to 8 wet diapers per day."
o C. "Your baby should sleep through the night."

, TEST BANK MATERNAL-NEWBORN NURSING THE CRITICAL
COMPONENTS OF NURSING CARE, 3RD EDITION, ROBERTA

o D. "Your baby should gain 1 ounce per day."
o Rationale: Six to eight wet diapers per day is an indicator
that the newborn is receiving adequate milk.
9. Which of the following findings should a nurse identify as a
complication of amniocentesis?
o A. Leakage of amniotic fluid
o B. Increase in fetal movement
o C. Maternal bradycardia
o D. Increased blood pressure
o Rationale: Leakage of amniotic fluid after an amniocentesis
can indicate a complication that requires further evaluation.
10. A nurse is preparing to administer vitamin K to a
newborn. The parent asks why this medication is necessary.
Which of the following responses should the nurse make?
o A. "It helps the baby to sleep better."
o B. "Newborns are deficient in vitamin K, which is
necessary for blood clotting."
o C. "It helps the baby's immune system."
o D. "Newborns need vitamin K for proper digestion."
o Rationale: Newborns are deficient in vitamin K, which is
necessary for blood clotting and preventing hemorrhagic
disease of the newborn.

11. A nurse is performing a newborn assessment. Which of
the following findings should the nurse report to the provider?
o A. Central cyanosis
o B. Vernix caseosa
o C. Acrocyanosis
o D. Lanugo
o Rationale: Central cyanosis indicates a potential respiratory
or cardiac issue that requires immediate attention, while
acrocyanosis, vernix caseosa, and lanugo are normal
findings.