PN Maternal Newborn Online Practice A Questions and Correct Solutions Graded A+

PN Maternal Newborn Online Practice A Questions with Complete Solutions Graded A+ A nurse is contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend in the plan? Take two docusate calcium capsules each evening Use a hypertonic enema when episodes occur. Consume 10 mL (2 tsp) of mineral oil each morning. Drink 2 L of water per day. - Answer: Drink 2 L of water per day. The client should drink 2 L of water (70.4 oz) per day to decrease reabsorption of fluid and prevent drying of stool, which causes constipation. A nurse is assisting in the care of 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? Facilitate the storage of iron in the fetus's liver Prevent certain kinds of birth defects Inhibit premature labor Aid in the absorption of other important nutrients - Answer: Prevent certain kinds of birth defects The nurse should inform the client that adequate folic acid intake prior to and during early pregnancy is necessary to help prevent neural tube defects. A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? IM Intradermal Subcutaneous Topical - Answer: Subcutaneous Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 hr. A nurse in a prenatal clinic is assisting in the care of a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take? Instruct the client to avoid crowds until a repeat hepatitis b test is negative. Tell the client that they will need to start the hepatitis B vaccine series after birth. Explain to the client that they will receive the hepatitis B immune globulin immediately. Inform the client that hepatitis B cannot be transmitted to the fetus. - Answer: Explain to the client that they will receive the hepatitis B immune globulin immediately. The nurse should explain to the client the need to receive the hepatitis immune globulin to decrease the risk of transmission to the fetus. The nurse should also instruct the client that all sexual partners and members of the client's household should see their providers to begin prophylactic treatment. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Secure padding in the newborn's fist on the affected side is nonessential. With Erbs-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers are unaffected. Therefore, there is no indication to place padding in the newborn's fist. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning their sleeve to their shirt. - Answer: Reinforce to parents to limit physical handling for 2 weeks is contraindicated. Parents need to participate in the physical care of their newborn to increase parental-infant attachment. Reinforcing teaching and providing practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding. Monitor extremity for edema is nonessential. Edema is not a manifestation of Erbs-Duchenne paralysis; however, a newborn who has a combination of Klumpke palsy and Erbs-Duchenne paralysis should be monitored for cyanosis and edema of the affected extremity. A nurse is assisting in the care of a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first? Check the newborn's blood glucose level. Place the newborn under a radiant warmer. Provide nonnutritive sucking. Swaddle the newborn. - Answer: Check the newborn's blood glucose level. The first action the nurse should take using the nursing process is to collect data from the client; therefore, the first action the nurse should take is to check the newborn's blood glucose level. A nurse is contributing to the plan of care for a client who is at 18 weeks gestation and has just learned that the fetus has trisomy 21. Which of the following resources should the nurse recommend for the client? Physical therapy Occupational therapy Palliative services Genetic counseling - Answer: Genetic counseling A fetus that has trisomy 21 (Down Syndrome) has an extra chromosome. Therefore, the nurse should recommend genetic counseling to provide the client further education about the prognosis and treatment of the condition, as well as offer support and guidance. A nurse in a maternal-newborn unit is assisting in the care of a newborn in the nursery. The newborn's grandparent asks if they may take the newborn to their daughter's room. Which of the following responses should the nurse make? "I'll first need to see your photo ID before I can release the baby to you." "Let me wash my hands and then I'll take the baby to their mother." "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room." "Have your daughter call the nursery so that the staff can release the baby to you." - Answer: "Let me wash my hands and then I'll take the baby to their mother." Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns. A nurse is assisting in the care of 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? Apgar score Newborn Hearing Screen Critical Congenital Heart Disease screen (CCHD) Neonatal Abstinence Scoring System - Answer: Neonatal Abstinence Scoring System This newborn is exhibiting manifestations of opioid withdrawal and should be screened using the Neonatal Abstinence Scoring System. Some additional manifestations of withdrawal include restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex. A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? Place the client in high-Fowler's position. Administer terbutaline subcutaneously. Apply oxygen at 2 L/min via nasal cannula. Insert an indwelling urinary catheter. - Answer: Insert an indwelling urinary catheter. The nurse should insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria. A nurse is reviewing the laboratory results of a 4-hr-old newborn. Which of the following laboratory findings should the nurse identify as a finding associated with neonatal sepsis and report to the provider? Hemoglobin level Bilirubin level Sodium level WBC count - Answer: WBC count The nurse should identify that a newborn who has a WBC count above or below the expected reference range may indicate neonatal sepsis. The nurse should report the WBC count to the provider. A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort? Prepare the client for a pudendal nerve block. Administer a sedative to the client. Encourage the client to push. Have the client perform relaxing breathing techniques. - Answer: Have the client perform relaxing breathing techniques. The nurse should encourage the client to perform relaxation techniques to promote comfort during the active phase of labor. A nurse is planning to reinforce discharge teaching about formula feeding with the parent of a newborn. Which of the following instructions should the nurse plan to include? Provide the newborn with six to eight feedings during a 24-hr period. Ensure that the newborn receives 45 to 60 mL of formula per feeding during the first 48 hr. Offer water to the newborn between feedings. Delay burping the newborn until the feeding is complete. - Answer: Provide the newborn with six to eight feedings during a 24-hr period. The parent should schedule the newborn's feedings every 3 to 4 hr. A nurse is observing a client bathe their 1-day-old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe the newborn? The client shakes powder from the container onto the newborn's skin. The client uses a cotton-tipped swab to clean the newborn's ears. The client washes the newborn's hair before unwrapping them. The client rinses the newborn under warm, running water. - Answer: The client washes the newborn's hair before unwrapping them. Keeping the newborn wrapped while washing their hair helps prevent heat loss. A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? 1 cup dried prunes 1/2 cup boiled potatoes 1/2 cup dried peas 1 cup grapes - Answer: 1/2 cup dried peas Clients who are pregnant should consume 400 mcg of folate per day. One-half cup of dried green split peas provides 127 mcg of folate and is the best of these sources of folate for the nurse to recommend. A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes? Ophthalmic Intramuscular Subcutaneous Rectal - Answer: Intramuscular The nurse should administer phytonadione intramuscularly to the newborn to prevent hemorrhage until the newborn's gastrointestinal system can produce its own vitamin K. A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will wipe the colostrum off my nipple before my baby feeds." "I should wake up my baby to feed during the night." "Since I am breastfeeding, I won't need to give my baby iron supplements until they're a year old." "I should start to pump my breasts after each feeding when I get home." - Answer: "I should wake up my baby to feed during the night." Guardians should awaken the newborn to feed every 3 hr at night for the first 24 to 48 hr after birth. Once the newborn is gaining weight, adequately progressing to demand feedings is safe. A nurse on a postpartum unit is organizing care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A client who reports constipation and is requesting a laxative A client who reports a moderate amount of dark red vaginal bleeding A client who had an epidural during labor and reports lower back pain rated a 4 on a 0 to 10 pain scale A client who is receiving methylergonovine and has a blood pressure of 148/96 mm Hg - Answer: A client who is receiving methylergonovine and has a blood pressure of 148/96 mm Hg When using the urgent versus nonurgent approach to client care, the nurse should plan to see this client first. Methylergonovine is a uterotonic medication used to treat postpartum hemorrhage and can cause significant hypertension. Therefore, the nurse should plan to see this client first to recheck the blood pressure, observe the amount of vaginal bleeding, and determine uterine tone. A nurse is collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider? Tinnitus Facial flushing Increased urine output Respiratory rate 10/min - Answer: Respiratory rate 10/min Respiratory depression is an indication of magnesium toxicity. The nurse should report this finding to the provider. Reinforcing education on medications is correct. The nurse should first reinforce the teaching with the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. - Answer: Administering ceftriaxone is correct. Ceftriaxone is designated as a stat prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after reinforcing teaching with the adolescent about the purpose and potential adverse reactions of the medication. A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension with a client who is at 16 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching? "I will apply support stockings 30 minutes after getting out of bed." "I will lie on my left side with my head elevated on a pillow." "I will cross my legs when sitting." "I will limit my salt intake." - Answer: "I will lie on my left side with my head elevated on a pillow." The nurse should instruct the client to avoid lying supine during pregnancy to prevent supine hypotension. The uterus compresses the inferior vena cava in the supine position, which decreases blood pressure and causes dizziness and fainting. Lying on the left side prevents compression of the vena cava and subsequent hypotension. A nurse is collecting data from a client who is a primigravida and has hyperthyroidism. Which of the following findings should the nurse expect? Lethargy Hoarseness Diaphoresis Cold intolerance - Answer: Diaphoresis Diaphoresis, heat intolerance, and tachycardia are expected findings with hyperthyroidism. A nurse is assisting with the care of a client who is at 39 weeks of gestation. Which of the following statements should alert the nurse as a sign of a potential complication? "I have pain in my upper right abdomen." "My feet and ankles are swollen." "I feel like I can't breathe when I'm lying down." "I have occasional numbness in my fingers." - Answer: "I have pain in my upper right abdomen." Epigastric pain can indicate hepatic involvement and severe preeclampsia. A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching? "The diaphragm should be removed 2 hours after having intercourse." "I can use water-soluble lubricant when my partner wears a latex condom." "It is okay for me to remove the birth control sponge within 2 hours after having intercourse." "When I use the birth control patch, it must be changed once a month." - Answer: "I can use water-soluble lubricant when my partner wears a latex condom." Water-soluble lubricants should be used with male latex condoms, because the use of any other lubricant can compromise the integrity of the condom. A nurse is reinforcing teaching with a client who is at 8 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching? "I should feel fetal movements by 12 weeks of pregnancy." "I should expect my pregnancy to start showing after the 20th week." "I should report occasional nausea and vomiting to the doctor immediately." "I should expect to have white vaginal discharge during pregnancy." - Answer: "I should expect to have white vaginal discharge during pregnancy." The client might experience leukorrhea, a white or gray vaginal discharge that occurs in response to increased estrogen and progesterone, throughout the entire pregnancy. A nurse is caring for a client who is at 32 weeks gestation and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication? Fetal lung maturity Maternal blood glucose control Cessation of uterine contractions Resolution of maternal nausea - Answer: Cessation of uterine contractions Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle of the uterus. A nurse is assisting in the care of a client following a cesarean birth. Which of the following actions should the nurse take to decrease the client's risk of developing thrombophlebitis? Have the client ambulate several times each day. Administer aspirin 80 mg orally once per day. Tell the client to expect leg pain for 48 hr. Apply warm compresses to the client's legs. - Answer: Have the client ambulate several times each day. The nurse should instruct the client to ambulate several times each day to increase circulation in the lower extremities and prevent thrombophlebitis. A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider? (Select all that apply.) Retractions Acrocyanosis Expiratory grunting Tachypnea Nasal flaring - Answer: Tachypnea is correct. Tachypnea is a respiratory rate greater than 60/min and is a finding associated with respiratory distress in the newborn. Nasal flaring is correct. Nasal flaring is a finding associated with respiratory distress in the newborn. Retractions is correct. Retractions are a finding associated with respiratory distress in the newborn. Expiratory grunting is correct. Expiratory grunting is a finding associated with respiratory distress in the newborn. A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? Acrocyanosis Heart rate 160/min Hypoglycemia Axillary temperature 36.5° C (97.7° F) - Answer: Hypoglycemia The nurse should identify that hypoglycemia is a blood glucose value that is below the expected reference range of 40 to 45 mg/dL for a newborn. A maternal history of gestational diabetes mellitus places the newborn at risk for hypoglycemia. Therefore, the nurse should report this finding to the provider. A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will report any drainage from my baby's umbilical cord." "I will wash my baby's umbilical cord with soapy water." "I will expect my baby's umbilical cord to fall off in 2 to 3 days." "I will secure the diaper over my baby's umbilical cord." - Answer: "I will report any drainage from my baby's umbilical cord." The client should report any drainage or foul odor from the umbilical cord because these are manifestations of infection. A nurse is assisting with the care of a client who is postpartum and is receiving lactated Ringer's 1,500 mL IV to infuse over 10 hr. The nurse should verify that the IV pump's settings will deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - Answer: Volume (mL)X mL/hr = Time (hr) X mL/hr = 150 mL/hr A nurse in a prenatal clinic is assisting in the care of a group of clients. Which of the following clients should the nurse recommend the provider see first? A client who is at 37 weeks of gestation and reports a persistent headache A client who is at 38 weeks of gestation and reports irregular uterine contractions A client who is at 12 weeks of gestation and reports abdominal cramping A client who is at 26 weeks of gestation and reports periodic numbness in the fingers - Answer: A client who is at 37 weeks of gestation and reports a persistent headache When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The nurse should identify that a persistent headache is a manifestation of preeclampsia and recommend that the provider see this client first. A nurse is reinforcing teaching about car seat safety with the guardian of a newborn. Which of the following client statements indicates an understanding of the teaching? "My baby should be in a rear-facing car seat until they are 6 months old and 15 pounds." "If my baby rides in a car with no back seat, the passenger air bag must be turned off." "It is dangerous to secure the car seat using the vehicle's seat belts." "I will place my baby's car seat at a 90° angle in the back seat." - Answer: "If my baby rides in a car with no back seat, the passenger air bag must be turned off." The nurse should reinforce to the parent that if a newborn cannot ride in the rear seat, the parent must disable the front passenger air bag to prevent potential injuries caused by air bag deployment. A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will massage my breasts while I take a shower." "I should wear an underwire bra during the day." "I should use a breast pump several times a day to relieve discomfort." "I will apply cold cabbage leaves to my breasts throughout the day." - Answer: "I will apply cold cabbage leaves to my breasts throughout the day." Frequent application of cold cabbage leaves to the breasts can prevent engorgement during lactation suppression for a client who is bottle-feeding her newborn. The client should also apply ice packs or cold compresses to her breasts, take mild analgesics, and wear a well-fitting and supportive bra. A nurse is planning to perform a blood collection via heel stick on a newborn. After performing hand hygiene and donning gloves, which of the following actions should the nurse plan to take next? Cleanse the newborn's heel with antiseptic and allow it to dry. Wrap the newborn's heel with a cloth moistened with warm water. Cuddle and comfort the newborn. Apply pressure to the newborn's heel by using a dry gauze square. - Answer: Wrap the newborn's heel with a cloth moistened with warm water. According to evidence-based practice, the nurse should first warm the newborn's heel by applying a cloth moistened with warm water for 5 to 10 min. This will allow dilation of the vessels in the area necessary to obtain an adequate sample. A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include? Instruct the client to discontinue feeding from the affected breast. Tell the client to wear an underwire bra. Instruct the client to apply warm compresses to the affected breast. Administer an antiviral medication. - Answer: Instruct the client to apply warm compresses to the affected breast. The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth. A nurse is monitoring a 1-hr-old newborn for hypoglycemia. For which of the following findings should the nurse monitor? (Select all that apply.) Twitching Hypothermia Abdominal distention Absent bowel sounds Tachypnea - Answer: Hypothermia is correct. Manifestations of hypothermia in newborns include hypothermia and diaphoresis. Twitching is correct. Manifestations of hypothermia in newborns include tremors and jitteriness. Tachypnea is correct. Tachypnea is a manifestation of respiratory distress, which can result from hypoglycemia due to maternal diabetes mellitus. A nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend? Encourage fluids with meals. Obtain a specimen for a uric acid level. Initiate a high-fat and low-protein diet. Monitor intake and output. - Answer: Monitor intake and output. The nurse should monitor intake and output to evaluate the client's hydration status and determine whether other interventions are necessary. A nurse on a postpartum unit is contributing to the discharge teaching plan for a client. Which of the following instructions should the nurse suggest for the plan? Apply powder to the newborn's skin after baths. Use a firm mattress in the newborn's crib. Cover the newborn with a crib comforter. Place the newborn on their stomach to sleep. - Answer: Use a firm mattress in the newborn's crib. The client should use a firm mattress in the newborn's crib to decrease the risk of sudden infant death syndrome. A nurse is assisting in the care of a client who is in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take? Check the client's blood pressure every 15 min for 1 hr after administration. Monitor the client's magnesium level. Inject the medication into the client's vastus lateralis muscle. Inform the client that the medication can cause dizziness. - Answer: Inject the medication into the client's vastus lateralis muscle. The nurse should administer the medication IM into the vastus lateralis muscle and administer a second dose 24 hr later. A nurse is reinforcing teaching about newborn home safety precautions with a group of parents. Which of the following instructions should the nurse include? "You should be able to place three fingers between the mattress and the sides of the crib." "You should ensure that crib slats are no more than 2.25 inches apart." "You should attach a pacifier to your baby's clothing." "You should set your water heater at 130° Fahrenheit." - Answer: "You should ensure that crib slats are no more than 2.25 inches apart." The nurse should reinforce that crib slats should be no more than 5.71 cm (2.25 in) apart to prevent entrapment, which can lead to extremity fractures and suffocation. A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first? Provide fundal massage for the client. Insert an indwelling urinary catheter for the client. Administer methylergonovine IM to the client. Administer oxygen via nonrebreather face mask to the client. - Answer: Provide fundal massage for the client. The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease bleeding. Clavicle fracture is associated with a difficult delivery of the shoulders. This complication can occur spontaneously during the birth of an LGA newborn and a vacuum-assisted birth. Manifestations of a clavicle fracture include the presence of crepitus over the fractured bone, decreased movement and an absent moro reflex in the affected arm. The palmar grasp reflex is present. Erb-Duchenne paralysis is the result of mechanical trauma to the spinal cord during a difficult birth. - Answer: This complication is more likely to occur during the birth of an LGA newborn and during a forceps or vacuum-assisted birth. Manifestations of Erb-Duchenne paralysis include a limp arm with absent spontaneous movement and absent moro reflex. The affected shoulder and arm are adducted and internally rotated with the wrist and fingers flexed. This results in a characteristic upwards positioning of the palm towards the back. The palmar grasp reflex is present because the paralysis is limited to the muscles in the upper arm.