1 Which nursing interventions promote thermal stability in the newborn immediately following
birth?
a. Provide skin to-skin contact immediately postpartum
2 The nurse is assessing a 6-hour old newborn. Which assessment findings should be reported to the
healthcare provider? Select all that apply. One, some, or all responses may be correct.
* Pulse rate greater than 160 beats/min or less than 110 beats/min
e Respirations greater than 60 breaths/min or less than 30 breaths/min
* Noisy respirations
* Nasal flaring or chest retraction
e Temperature elevated above 37.7° C (99.8* F) or below 36.2* C (97.1° F)
Respiratory distress syndrome
Nasal flaring
O
An apical heart rate of 100
/a0
Respiratory rate > 60 breaths/minute
3 The nurse is caring for a postpartum client following a cesarean section who is hypovolemic.
Which nursing diagnosis is most appropriate?
a. Risk for altered tissue perfusion
4 A postpartum client is experiencing prolonged lochia discharge with irregular bleeding. A pelvic
exam reveals an enlarged uterus. The nurse identifies the findings as consistent with which
condition?
a. Subinvolution of the uterus
5 A client is prescribed Heparin 4,000 units subcutaneous injection. The pharmacy supplies 5,000
units/mL. The nurse will administer (1) mL. Round to the nearest tenth.
a. 0.8
6 Which of the following is a priority assessment in a newborn whose mother has a history of
diabetes?
a. Hypoglycemia
7 A client is prescribed Meperidine 30mg IM q4hr pain as needed. The pharmacy delivers
Meperidine 40mg/mL. The nurse will administer (1) mL. Round to the nearest tenth.
a. 0.8
8 Which describes the benefit of skin-to-skin contact immediately following delivery? Select all that
apply. One, some, or all responses may be correct.
a. Positive maternal infant bonding
b. Stable body temperature
c. Cardiopulmonary stability
9 The nurse is assessing an infant who is 12 hours old. The nurse notes that the infant does not take
a breath for 18 seconds, and breathing is uneven. What is the proper intervention?
a. Give oxygen at 10 L blow-by
10 The nurse observes a newborn has limited arm motion on one side and, during palpation of the
clavicles, notes the presence of crepitus. Which type of birth injury does the nurse suspect?
a. Fractured clavicle
, 11 The nurse is caring for a client diagnosed with chorioamnionitis. Which clinical manifestation
will the nurse expect to assess? Select all that apply. One, some, or all responses may be correct.
Maternal fever
Fetal tachycardia
o
Foul smelling amniotic fluid
/e
Uterine tenderness
12 A client is prescribed 800 mg of liquid ibuprofen. The nurse has available ibuprofen 250 mg/mL.
The nurse will administer (1) mL. Round to the nearest whole number.
a. 3
13 A mother of a breastfed infant expresses concern over her infant's stools being yellow. Which is
an appropriate response?
a. "This is normal for breastfed babies.
14 nurse is caring for a postpartum mother who Is experiencing occasional periods of sadness,
anxiety, and difficulty to sleep. The client continues to be active in the infant’s care and displays
appropriate bonding with her child. The nurse explains to the client that she is experiencing which
of the following conditions?
a. Baby blues
15 Which instructions would the nurse include in the teaching plan for a postpartum client with
mastitis?
a. Try applying warm compresses to your breasts to encourage the milk to be released.
16 Which assessment is a priority for a new mother breastfeeding for the first time?
a. Assess the infant's position and ability to latch
17 Which of the following is a priority assessment for the infant born to a mother with drug
addiction?
a. Signs of withdrawal
18 The nurse assessing a newborn notes a bluish-gray patch resembling a bruise across the infant's
buttocks. Which term is used to describe the nurse's assessment finding?
a. Mongolian spots
19 The nurse is caring for a full-term newborn 6 hours old. Which assessment finding indicates the
need for immediate intervention?
a. Nasal flaring and grunting
20 A client is prescribed methergine 0.8 mg IM. The nurse has available 0.2mg/ml. The nurse
should administer-——-ml.
a. 4
21 When teaching a mother to care for her newborn's umbilical cord, which instruction will the
nurse include in the teaching plan?
a. Keep cord dry
po.
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birth?
a. Provide skin to-skin contact immediately postpartum
2 The nurse is assessing a 6-hour old newborn. Which assessment findings should be reported to the
healthcare provider? Select all that apply. One, some, or all responses may be correct.
* Pulse rate greater than 160 beats/min or less than 110 beats/min
e Respirations greater than 60 breaths/min or less than 30 breaths/min
* Noisy respirations
* Nasal flaring or chest retraction
e Temperature elevated above 37.7° C (99.8* F) or below 36.2* C (97.1° F)
Respiratory distress syndrome
Nasal flaring
O
An apical heart rate of 100
/a0
Respiratory rate > 60 breaths/minute
3 The nurse is caring for a postpartum client following a cesarean section who is hypovolemic.
Which nursing diagnosis is most appropriate?
a. Risk for altered tissue perfusion
4 A postpartum client is experiencing prolonged lochia discharge with irregular bleeding. A pelvic
exam reveals an enlarged uterus. The nurse identifies the findings as consistent with which
condition?
a. Subinvolution of the uterus
5 A client is prescribed Heparin 4,000 units subcutaneous injection. The pharmacy supplies 5,000
units/mL. The nurse will administer (1) mL. Round to the nearest tenth.
a. 0.8
6 Which of the following is a priority assessment in a newborn whose mother has a history of
diabetes?
a. Hypoglycemia
7 A client is prescribed Meperidine 30mg IM q4hr pain as needed. The pharmacy delivers
Meperidine 40mg/mL. The nurse will administer (1) mL. Round to the nearest tenth.
a. 0.8
8 Which describes the benefit of skin-to-skin contact immediately following delivery? Select all that
apply. One, some, or all responses may be correct.
a. Positive maternal infant bonding
b. Stable body temperature
c. Cardiopulmonary stability
9 The nurse is assessing an infant who is 12 hours old. The nurse notes that the infant does not take
a breath for 18 seconds, and breathing is uneven. What is the proper intervention?
a. Give oxygen at 10 L blow-by
10 The nurse observes a newborn has limited arm motion on one side and, during palpation of the
clavicles, notes the presence of crepitus. Which type of birth injury does the nurse suspect?
a. Fractured clavicle
, 11 The nurse is caring for a client diagnosed with chorioamnionitis. Which clinical manifestation
will the nurse expect to assess? Select all that apply. One, some, or all responses may be correct.
Maternal fever
Fetal tachycardia
o
Foul smelling amniotic fluid
/e
Uterine tenderness
12 A client is prescribed 800 mg of liquid ibuprofen. The nurse has available ibuprofen 250 mg/mL.
The nurse will administer (1) mL. Round to the nearest whole number.
a. 3
13 A mother of a breastfed infant expresses concern over her infant's stools being yellow. Which is
an appropriate response?
a. "This is normal for breastfed babies.
14 nurse is caring for a postpartum mother who Is experiencing occasional periods of sadness,
anxiety, and difficulty to sleep. The client continues to be active in the infant’s care and displays
appropriate bonding with her child. The nurse explains to the client that she is experiencing which
of the following conditions?
a. Baby blues
15 Which instructions would the nurse include in the teaching plan for a postpartum client with
mastitis?
a. Try applying warm compresses to your breasts to encourage the milk to be released.
16 Which assessment is a priority for a new mother breastfeeding for the first time?
a. Assess the infant's position and ability to latch
17 Which of the following is a priority assessment for the infant born to a mother with drug
addiction?
a. Signs of withdrawal
18 The nurse assessing a newborn notes a bluish-gray patch resembling a bruise across the infant's
buttocks. Which term is used to describe the nurse's assessment finding?
a. Mongolian spots
19 The nurse is caring for a full-term newborn 6 hours old. Which assessment finding indicates the
need for immediate intervention?
a. Nasal flaring and grunting
20 A client is prescribed methergine 0.8 mg IM. The nurse has available 0.2mg/ml. The nurse
should administer-——-ml.
a. 4
21 When teaching a mother to care for her newborn's umbilical cord, which instruction will the
nurse include in the teaching plan?
a. Keep cord dry
po.
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