CMS Maternal Newborn Practice
_____________Quiz____________?
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
_____________Quiz____________?
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
_____________Quiz____________?
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
1
, Occurs due to the breakdown of fat secondary to malnutrition or starvation
Tachycardia and tachypnea due to dehydration
_____________Quiz____________?
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
_____________Quiz____________?
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
2
, - 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
_____________Quiz____________?
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
_____________Quiz____________?
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.
_____________Quiz____________?
3
_____________Quiz____________?
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
_____________Quiz____________?
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
_____________Quiz____________?
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
1
, Occurs due to the breakdown of fat secondary to malnutrition or starvation
Tachycardia and tachypnea due to dehydration
_____________Quiz____________?
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
_____________Quiz____________?
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
2
, - 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
_____________Quiz____________?
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
_____________Quiz____________?
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.
_____________Quiz____________?
3
