CMS Maternal Newborn Practice TEST VERIFIED SOLUTIONS

CMS Maternal Newborn Practice TEST VERIFIED SOLUTIONS 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 - indication of preeclampsia Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr, leg cramps A nurse is caring or 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 - to prevent damage to the retinas - Should remove mask for feedings DO NOT apply a thin layer of lotion to the newborn's skin 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 Occurs due to the breakdown of fat secondary to malnutrition or starvation Tachycardia and tachypnea due to dehydration A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete? - ANSWER Neonatal Abstinence Scoring System: exhibiting opioid withdrawal Additional manifestations: restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex - Apgar score: heart rate, respiratory rate, muscle tone, reflex irritability and skin color - Newborn Hearing Screen should be completed before the newborn is discharged from the hospital - Critical Congenital Heart Disease screen should be completed 24- 28 hours following birth and before the newborn is discharged from the hospital A nurse is assisting in the care of a newborn immediately following birth. Which of the following images should the nurse identify as an indication that the newborn has a myelomeningocele? - ANSWER Occurs when the neural tube fails to close, and the meninges and spinal cord herniate Occurs in the lumbar area and may be covered by a thin membranous sac - Exstrophy of the bladder; occurs from abnormal development of the abdominal wall, symphysis pubis and bladder ; visible in the suprapubic area and requires surgical intervention soon after birth - Omphalocel: occurs when abdominal organs herniate through the umbilical ring at the base of the umbilical cord - Cephalohematoma; collection of blood between the skull bone and its covering, the periosteum. A cephalohematoma does not cross the suture lines of the newborn's skull and will spontaneously resolve in 2-8 weeks A nurse is collecting data from a newborn who is 8hr old. Which of the following findings should the nurse report to the provider? - ANSWER Apical heart rate of 90/min while crying - normal range 110 - 160 for a newborn, heart rate of 80-100/min while asleep and up to 180/min while crying - Apneic episode of 20 seconds or less - normal; newborns respirations are normally shallow and irregular - Positive moro reflex present from birth up to 8 weeks - Vernix in the skin folds - normal A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority? a. administer analgesics b. apply an ice pack to the perineum c. assist the client with breastfeeding d. help the client ambulate to the toilet - ANSWER d. help the client ambulate to the toilet The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to assist the client to urinate and completely empty the bladder, which will allow the uterus to contract. A nurse is reinforcing teaching with a client who is at 20 wks of gestation and has gestational diabetes mellitus. Which of the following information should the nurse include in the teaching? a. exercise before meals b. consume at least 2,000 cal/day c. avoid consuming an evening snack d. maintain a fasting blood glucose of 110 to 120 mg/dL - ANSWER b. consume at least 2,000 cal/day This will ensure adequate glucose intake and prevent hypoglycemia. Exercise should be done after meals to prevent hypoglycemia. Should have an evening snack to prevent hypoglycemia during the night. Should maintain a fasting blood glucose of less than 95 mg/dL. A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in newborns with a group of clients who are pregnant. Which of the following risk factors should the nurse include? a. cord compression b. chronic hypertension c. alcohol use during pregnancy d. prematurity - ANSWER d. prematurity A newborn who is premature has inadequate surfactant production, which can lead to RDS. Alcohol syndrome can result in fetal alcohol syndrome, developmental delay, and birth defects. Cord compression can result in fetal anoxia. A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following? a. facilitate the storage of iron in the fetus liver b. prevent certain kinds of birth defects c. inhibit premature labor d. aid in the absorption of o