RN Maternal Newborn Online Practice
2019 A
A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?
A. "You can resume sexual activity in 1 week."
B. "You won't need to do Kegel exercises since you had a cesarean."
C. "You can still become pregnant if you are breastfeeding."
D. "You are safe to start adding sit-ups to your exercise routine in 2 weeks." - Ans C. You can still become pregnant if you are breastfeeding
- MY ANSWERThe nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.
Rationale: A. The nurse should instruct the client that it is safe to resume sexual activity once all vaginal bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is highly recommended that the client wait until after her 6-week follow-up with the provider because the incision and healing process should be assessed before sexual activity is resumed.
B. The nurse should instruct the client to continue to perform Kegel exercises to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. D. The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a cesarean
birth. The nurse can instruct the client to perform other exercises such as walking, arm raises, and leg rolls.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?
A. Check the client's capillary refill.
B. Massage the client's fundus.
C. Insert an indwelling urinary catheter for the client. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr.
However, another action is the nurse's priority.
D. Prepare the client for a blood transfusion. - Ans B. Massage the clients fundus.
- Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.
Rationale: A. It is important for the nurse to monitor capillary refill to track baseline data for this client. Noninvasive
assessments of cardiac output for clients who are experiencing postpartum hemorrhage include assessing: capillary refill; skin color, temperature, and turgor; level of consciousness; neck veins; and mucous membranes. However, another action is the nurse's priority.
C. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr. However, another action is the nurse's priority. D. It is important for the nurse to prepare the client for a blood transfusion to replace the amount of blood lost from postpartum hemorrhage. It is crucial to restore circulating blood volume. However, another action is the nurse's priority.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
A. Late decelerations B. Moderate variability of the FHR
C. Cessation of uterine dilation
D. Prolonged active phase of labor - Ans A. Late declarations
- Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.
Rationale: B. Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-
base balance. It is not a contraindication to the administration of oxytocin.
C. Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.
D. A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? A. 2+ deep tendon reflexes
B. Proteinuria of 200 mg in a 24-hr specimen
C. Polyuria D. Blurred vision - Ans D. Blurred vision
- The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
Rationale: A. The nurse should identify that a client who has severe preeclampsia can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or expected response.
B. The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is greater than 500 mg in a 24-hr specimen.
C. The nurse should identify that a client who has severe preeclampsia can have decreased urine output or oliguria of 20 mL/hr or less than 400 to 500 mL in 24 hr. This is related to decreased perfusion of the kidneys and possible glomerular damage.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plain to prepare the client for which of the following diagnostic tests?
A. Biophysical profile
B. Amniocentesis
2019 A
A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?
A. "You can resume sexual activity in 1 week."
B. "You won't need to do Kegel exercises since you had a cesarean."
C. "You can still become pregnant if you are breastfeeding."
D. "You are safe to start adding sit-ups to your exercise routine in 2 weeks." - Ans C. You can still become pregnant if you are breastfeeding
- MY ANSWERThe nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.
Rationale: A. The nurse should instruct the client that it is safe to resume sexual activity once all vaginal bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is highly recommended that the client wait until after her 6-week follow-up with the provider because the incision and healing process should be assessed before sexual activity is resumed.
B. The nurse should instruct the client to continue to perform Kegel exercises to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. D. The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a cesarean
birth. The nurse can instruct the client to perform other exercises such as walking, arm raises, and leg rolls.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?
A. Check the client's capillary refill.
B. Massage the client's fundus.
C. Insert an indwelling urinary catheter for the client. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr.
However, another action is the nurse's priority.
D. Prepare the client for a blood transfusion. - Ans B. Massage the clients fundus.
- Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.
Rationale: A. It is important for the nurse to monitor capillary refill to track baseline data for this client. Noninvasive
assessments of cardiac output for clients who are experiencing postpartum hemorrhage include assessing: capillary refill; skin color, temperature, and turgor; level of consciousness; neck veins; and mucous membranes. However, another action is the nurse's priority.
C. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr. However, another action is the nurse's priority. D. It is important for the nurse to prepare the client for a blood transfusion to replace the amount of blood lost from postpartum hemorrhage. It is crucial to restore circulating blood volume. However, another action is the nurse's priority.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
A. Late decelerations B. Moderate variability of the FHR
C. Cessation of uterine dilation
D. Prolonged active phase of labor - Ans A. Late declarations
- Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.
Rationale: B. Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-
base balance. It is not a contraindication to the administration of oxytocin.
C. Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.
D. A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? A. 2+ deep tendon reflexes
B. Proteinuria of 200 mg in a 24-hr specimen
C. Polyuria D. Blurred vision - Ans D. Blurred vision
- The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
Rationale: A. The nurse should identify that a client who has severe preeclampsia can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or expected response.
B. The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is greater than 500 mg in a 24-hr specimen.
C. The nurse should identify that a client who has severe preeclampsia can have decreased urine output or oliguria of 20 mL/hr or less than 400 to 500 mL in 24 hr. This is related to decreased perfusion of the kidneys and possible glomerular damage.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plain to prepare the client for which of the following diagnostic tests?
A. Biophysical profile
B. Amniocentesis
