A..T..I.. Maternal Newborn Practice B (version 3)/ Maternal Newborn Practice B(LATEST)|ALL ANSWERS VERIFIED,100% CORRECT

Maternal Newborn

1. 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."
Colostrum contains immunoglobulins, which provide passive immunity

to the newborn. Colostrum also facilitates the newborn's passage of

meconium. Therefore, the client should not remove the colostrum from

her nipple prior to breastfeeding.
"I should wake up my baby to feed during the night."
Parents should awaken the newborn to feed every 4 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.
"Since I am breastfeeding, I won't need to give my baby iron supplements
until he's a year old."
After 6 months of age, all infants need to ingest iron-fortified cereal and

other foods rich in iron.
"I should start to pump my breasts after each feeding when I get home."
Pumping after breastfeeding can lead to an oversupply of breast milk.

The client should use the breast pump if the newborn is not able to feed

at the breast. After breastfeeding is well-established, the client can pump

intermittently to establish a reserve supply of breast milk if desired.

2. 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

,Tinnitus is not an indication of magnesium toxicity and not a finding

associated with preeclampsia.
Proteinuria 3+
Proteinuria 3+ is an indication of preeclampsia rather than magnesium

toxicity.
Increased urine output
Magnesium sulfate is normally excreted in the urine. Decreased urine

output can lead to inadequate elimination of the medication, which can

result in magnesium toxicity.
Respiratory rate 10/min
Respiratory depression is an indication of magnesium toxicity. The nurse

should report this finding to the provider.

3. A nurse is collecting data from a client who is at 37 weeks of
gestation. Which of the following findings should the nurse report to
the provider?
Leukorrhea
The nurse should identify that leukorrhea, or vaginal discharge, is an

expected finding during pregnancy.
Nonpitting ankle edema
The nurse should identify that nonpitting ankle edema is an expected

finding during the third trimester of pregnancy.
Tingling in fingers
The nurse should identify that tingling in fingers is an expected finding

during pregnancy due to traction on the brachial plexus nerves.
Blurred vision

,The nurse should identify that blurred vision or double vision are

manifestations of gestational hypertension or preeclampsia. The nurse

should report this finding to the provider.

4. A nurse is reviewing the medical record of a client who is at 26
weeks of gestation. Which of the following findings should the nurse
identify as a risk factor for the development of preeclampsia?
Rheumatoid arthritis
The nurse should identify that connective tissue diseases, such as

rheumatoid arthritis and systemic lupus erythematosus, increase a client's

risk for preeclampsia.
BMI of 24
The nurse should identify that obesity, or a BMI greater than 30,

increases a client's risk for preeclampsia. Other risk factors include

multifetal gestation, infection, and chronic hypertension.
Iron-deficiency anemia
The nurse should identify that iron-deficiency anemia does not increase

the client's risk for preeclampsia. Risk factors include multifetal

gestation, infection, and chronic hypertension.
Oligohydramnios
The nurse should identify that oligohydramnios, or less than 300 mL of

amniotic fluid, does not increase the client's risk for preeclampsia. Risk

factors include multifetal gestation, infection, and chronic hypertension.

5. A nurse is reinforcing teaching about car seat safety with the
guardian of a newborn. Which of the following statements by the
guardian indicates an understanding of the teaching?
"I will place the baby's car seat in a rear-facing position until she is 1 year
old."

, The guardian should position the newborn's car seat rear-facing in the

middle of the back seat until she is 2 years old, or as long as she meets

the height and weight restrictions set by the car seat's manufacturer.
"I will position the retainer clip at the level of the baby's armpits."
The guardian should position the retainer clip at the level of the

newborn's axillae and not over the neck or abdomen.
"I will place the shoulder harness straps in a slot 2 inches above the
baby's shoulders."
The guardian should place the shoulder harness straps in the slots at or

below the level of the newborn's shoulders.
"I will position the baby at a 60-degree angle in the car seat."
The guardian should position the newborn in the car seat at a 45° angle

to prevent the newborn's head from falling forward, which can lead to

airway obstruction and suffocation.

6. A nurse is contributing to the plan of care for a client who has
eclampsia. Which of the following interventions should the nurse
identify and plan to include as the priority immediately following a
seizure?
Initiate an IV line with an 18-gauge needle.
The nurse should use an 18-gauge catheter to administer magnesium

sulfate to the client; however, there is another action the nurse should

take first.
Insert an indwelling urinary catheter.
The nurse should insert an indwelling urinary catheter to monitor the

client's output; however, there is another action the nurse should take

first.
Administer oxygen via facemask at 10 L/min.