Maternal newborn online practice 2019 A with rationale REVISE 2023/2024

Maternal newborn online practice 2019 A with rationale REVISE 2023/2024 A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? - ANSWER - Reports increased urinary output Rationale: Increased urinary output, n/v, reports of thirst, abd. pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL. A nurse is caring for a client who is at 22 weeks gestation and is HIV positive. Which of the following actions should the nurse take? - ANSWER -Report the clients condition to the health department Rationale: HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? - ANSWER -Depression Rationale: The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common AE of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. A nurse if providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? - ANSWER -"I can administer oxytocin 4 hours after the insertion of the medication." Rationale: The nurse can administer oxytocin no sooner than 4 hours after the last dose of misoprostol. Oxytocin can be administered following misprostol for clients who have cervical ripening and have not begun labor. A nurse is caring for a prenatal client who has parvovirus B19 (5th disease). Which of the following actions should the nurse take? - ANSWER - Schedule an ultrasound examination Rationale: to monitor fetus during the pregnancy to detect the possible development of fetyal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. A nurse is preparing to collect a blood speciman from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? - ANSWER -Place the newborn skin to skin on the mother's chest -Rationale:Place the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? - ANSWER - insert two gloved fingers into the vagina and apply upward pressure to the presenting part. Rationale: exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. A nurse is caring for a client who is at 24 weeks gestation and has a suspected placental abruption. Which of the following lab tests should the nurse expect the provider to prescribe? - ANSWER -Kleihaurer-Betke test Rationale: test is performed on a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho- (D) immune globulin therapy should be administered to a client who is Rh-negative. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? - ANSWER -Abruptio placenta Rationale: Cocaine use increases the risk for vasoconstriction and possible abruptio placenta. A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? - ANSWER -Blurred vision Rationale: 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. A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7 year old child in accepting the new family member? - ANSWER -Obtain a gift from the newborn to present to the sibling Rationale: Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures the sibling doesnt feel left out and that they understand their role in the family. A nurse is assessing a client who is receiving morphine via IV bolus for pain follow a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? - ANSWER -Naloxone Rationale: Morphine is a common opioid analgesic used for post-op pain management that can cause CNS depression and can cause respiratory depression. The nurse should administer nalaxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client. A nurse is teaching a client who is at 10 weeks gestation about nutrition during pregnancy. Which of the following statements by the client indicated an understanding of the teaching? - ANSWER -"I should take 600 mcg of folic acid each day. Rationale: A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube defects. A nurse is assessing a newborn 12 hours after birth. Which of the following manifestation should the nurse report to the provider? - ANSWER -Jaundice Rationale: Jaundice occurring within the first 24 hours of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? - ANSWER -Lays the newborn across her lap and gently sways Rationale: correct technique for quieting newborn. This tactile stimulation promotes a sense of security for the newborn. A nurse is teaching a newly licensed nurse about collecting a speciman for the universal newborn screening. Which of the following statement should the nurse include in the teaching? - ANSWER -Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the speciman Rationale: Premature newborns may have false negative tests due to immature development of liver enzymes. 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? - ANSWER - Massage the client's fundus Rationale: uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can comprimise the perfusion to the clients vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss. A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? - ANSWER - Acrocyanosis -Positive Babinski reflex -Two umbilical arteries visable Rationale: Acrocyanosis is an expected finding for at least 24 hours following birth. Poor peripheral perfusion leads to bluish discoloration in the newborns hands and feet. Pos. Babinski reflex is correct. nurse should stroke the newborns foot upward from heel to toe. The toes should hyperextend, and dorsal flexion of the big toe should occur. Absense of this finding requires neurological evaluation. The nurse should observe 2 arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. A nurse is demonstrating to a client how to bathe their newborn. - ANSWER -wipe the newborns eyes from the inner canthus outward -Wash the newborns neck by lifting the newborn's chin - Cleanse the skin around the newborns umbilical cord stump -wash the newborns legs and feet -clean the newborns diaper area