Christina Han
Maternal Newborn Practice A
1. 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?
Ketonuria
The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat
secondary to malnutrition or starvation.
Bradycardia
The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachycardia due to dehydration.
Bradypnea
The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachypnea due to dehydration.
Proteinuria
The nurse should identify that proteinuria is an indication of preeclampsia, rather than hyperemesis gravidarum.
2. A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting.
Which of the following instructions should the nurse include?
Eat foods that are served hot.
The nurse should instruct the client that she will better tolerate foods that are served cold or at room temperature.
Drink 360 mL (12 oz) of fluids during mealtimes
The client should avoid drinking liquid with meals because this increases the risk for nausea. The client should alternate consumption
of fluids and foods every 2 to 3 hr throughout the day.
Consume small meals frequently each day.
The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this
increases nausea.
Eat a high-protein snack before getting out of bed.
The nurse should instruct the client to consume a snack high in carbohydrates, such as crackers, before getting out of bed in the
morning to decrease nausea.
3. A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the
newborn to his daughter's room. Which of the following responses should the nurse make?
"I'll first need to see your photo ID before I can release the baby to you."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns.
"Let me wash my hands and then I'll take your grandson to his mother."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns.
"Please wash your hands first, then I'll allow you to carry the baby to your daughter's room."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns. In addition, transport of the newborn must be in a designated bassinet.
"Have your daughter call the nursery so that the staff can release the baby to you."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns
,4. A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the
following instructions should the nurse include in the teaching?
Avoid using a breast pump during times of engorgement.
The nurse should instruct the client to use a breast pump during engorgement to soften the breasts prior to breastfeeding. The client
can also use a breast pump after feedings to empty the breasts completely.
Apply warm compresses to the breasts after feedings.
The nurse should instruct the client to apply cold compresses to the breasts after feedings to decrease discomfort. The client can take a
warm shower immediately before breastfeeding to soften the breasts.
Decrease daily fluid intake.
The nurse should instruct the client to drink enough fluids each day to satisfy her thirst. Decreased fluid intake can decrease milk
production.
Breastfeed the newborn at least every 2 hr.
The nurse should instruct the client to breastfeed the newborn every 2 hr during engorgement. Frequent feedings soften the breasts
and decrease pain.
5. A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding.
Which of the following actions should the nurse take first?
Provide fundal massage for the client.
The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should
take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease
bleeding.
Insert an indwelling urinary catheter for the client.
Inserting an indwelling urinary catheter is important to eliminate bladder distention and monitor urinary output. However, this is not
the first action the nurse should take.
Administer methylergonovine IM to the client.
Administering methylergonovine to enhance uterine contractions is an action the nurse should take to manage postpartum
hemorrhage. However, this is not the first action the nurse should take.
Administer oxygen via nonrebreather face mask to the client.
Administering oxygen via nonrebreather face mask is an action the nurse should take to enhance oxygenation to the cells. However,
this is not the first action the nurse should take
6. A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements
indicates an understanding of the teaching?
"This medication might make me dizzy."
Butorphanol tartrate is an opioid medication that can cause dizziness, sedation, and hallucinations.
"This medication might cause me to breathe very fast."
Butorphanol tartrate is an opioid medication that can cause respiratory depression.
"This medication will last for 10 to 12 hours."
Butorphanol tartrate is an opioid medication that has a duration of action of 3 to 4 hr.
"This medication will cause my stools to be loose and watery."
Butorphanol tartrate is an opioid medication that has adverse effects of constipation, nausea, vomiting, confusion, and sedation.
, 7. A nurse is collecting data from a client who is in her second trimester of pregnancy. Which of the following findings should the
nurse report to the provider?
Increased leukorrhea
Increased leukorrhea is a whitish discharge which is an expected finding due to the hormonal changes that occur during pregnancy.
Hyperpigmentation of the face
Hyperpigmentation of the face is also known as the "mask of pregnancy" and is an expected finding due to the hormonal changes that
stimulate melanocytes that occur during pregnancy.
Varicose veins
Varicose veins are an expected finding during pregnancy due to hormonal influence on the smooth muscle walls of veins. The growing
fetus can exacerbate varicose veins in a pregnant woman.
Frequent uterine contractions
The nurse should report frequent uterine contractions during the second trimester to the provider because they can cause the cervix
to open early and subject the client to preterm labor.
8. A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect?
Saturation of one perineal pad every 15 min
The nurse should not expect saturation of one perineal pad every 15 min as this indicates postpartum hemorrhage, which could lead to
hypovolemic shock.
Fundus 2 cm above the umbilicus
At 32 hr postpartum, the client's fundus should be 1 to 2 cm below the umbilicus. The fundus should descend 1 cm per day after birth.
Temperature of 39° C (102.2° F)
The nurse should identify that a temperature higher than 38° C (100.4° F) after the first 24 hr can indicate infection in a client who is 32
hr postpartum.
Urine output of 3,000 mL in 24 hr
The nurse should expect postpartum diuresis to begin approximately 12 hr after delivery. Therefore, a urine output of 3,000 mL in 24
hr is an expected finding for this client.
9. A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should
the nurse report to the provider?
Calcium 9.2 mg/dL
The nurse should identify that a calcium level of 9.2 mg/dL is within the expected reference range of 7.6 to 10.4 mg/dL for a newborn.
Heart rate 160/min
The nurse should identify that a heart rate of 160/min is within the expected reference range of 110 to 160/min for a newborn. A heart
rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn.
Blood glucose 28 mg/dL
The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 30 to 60 mg/dL for a newborn.
Therefore, the nurse should report this finding to the provider.
Axillary temperature 36.5 C(97.7 F)
The nurse should identify that a temperature for a healthy newborn averages 37 C (98.6 F), with a range of 36.5C to 37.5 C (97.7F to
99.5 F).
10. A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify
as an indication of a potential complication of pregnancy?
Maternal Newborn Practice A
1. 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?
Ketonuria
The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat
secondary to malnutrition or starvation.
Bradycardia
The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachycardia due to dehydration.
Bradypnea
The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachypnea due to dehydration.
Proteinuria
The nurse should identify that proteinuria is an indication of preeclampsia, rather than hyperemesis gravidarum.
2. A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting.
Which of the following instructions should the nurse include?
Eat foods that are served hot.
The nurse should instruct the client that she will better tolerate foods that are served cold or at room temperature.
Drink 360 mL (12 oz) of fluids during mealtimes
The client should avoid drinking liquid with meals because this increases the risk for nausea. The client should alternate consumption
of fluids and foods every 2 to 3 hr throughout the day.
Consume small meals frequently each day.
The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this
increases nausea.
Eat a high-protein snack before getting out of bed.
The nurse should instruct the client to consume a snack high in carbohydrates, such as crackers, before getting out of bed in the
morning to decrease nausea.
3. A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the
newborn to his daughter's room. Which of the following responses should the nurse make?
"I'll first need to see your photo ID before I can release the baby to you."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns.
"Let me wash my hands and then I'll take your grandson to his mother."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns.
"Please wash your hands first, then I'll allow you to carry the baby to your daughter's room."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns. In addition, transport of the newborn must be in a designated bassinet.
"Have your daughter call the nursery so that the staff can release the baby to you."
Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-
newborn unit should transport newborns
,4. A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the
following instructions should the nurse include in the teaching?
Avoid using a breast pump during times of engorgement.
The nurse should instruct the client to use a breast pump during engorgement to soften the breasts prior to breastfeeding. The client
can also use a breast pump after feedings to empty the breasts completely.
Apply warm compresses to the breasts after feedings.
The nurse should instruct the client to apply cold compresses to the breasts after feedings to decrease discomfort. The client can take a
warm shower immediately before breastfeeding to soften the breasts.
Decrease daily fluid intake.
The nurse should instruct the client to drink enough fluids each day to satisfy her thirst. Decreased fluid intake can decrease milk
production.
Breastfeed the newborn at least every 2 hr.
The nurse should instruct the client to breastfeed the newborn every 2 hr during engorgement. Frequent feedings soften the breasts
and decrease pain.
5. A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding.
Which of the following actions should the nurse take first?
Provide fundal massage for the client.
The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should
take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease
bleeding.
Insert an indwelling urinary catheter for the client.
Inserting an indwelling urinary catheter is important to eliminate bladder distention and monitor urinary output. However, this is not
the first action the nurse should take.
Administer methylergonovine IM to the client.
Administering methylergonovine to enhance uterine contractions is an action the nurse should take to manage postpartum
hemorrhage. However, this is not the first action the nurse should take.
Administer oxygen via nonrebreather face mask to the client.
Administering oxygen via nonrebreather face mask is an action the nurse should take to enhance oxygenation to the cells. However,
this is not the first action the nurse should take
6. A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements
indicates an understanding of the teaching?
"This medication might make me dizzy."
Butorphanol tartrate is an opioid medication that can cause dizziness, sedation, and hallucinations.
"This medication might cause me to breathe very fast."
Butorphanol tartrate is an opioid medication that can cause respiratory depression.
"This medication will last for 10 to 12 hours."
Butorphanol tartrate is an opioid medication that has a duration of action of 3 to 4 hr.
"This medication will cause my stools to be loose and watery."
Butorphanol tartrate is an opioid medication that has adverse effects of constipation, nausea, vomiting, confusion, and sedation.
, 7. A nurse is collecting data from a client who is in her second trimester of pregnancy. Which of the following findings should the
nurse report to the provider?
Increased leukorrhea
Increased leukorrhea is a whitish discharge which is an expected finding due to the hormonal changes that occur during pregnancy.
Hyperpigmentation of the face
Hyperpigmentation of the face is also known as the "mask of pregnancy" and is an expected finding due to the hormonal changes that
stimulate melanocytes that occur during pregnancy.
Varicose veins
Varicose veins are an expected finding during pregnancy due to hormonal influence on the smooth muscle walls of veins. The growing
fetus can exacerbate varicose veins in a pregnant woman.
Frequent uterine contractions
The nurse should report frequent uterine contractions during the second trimester to the provider because they can cause the cervix
to open early and subject the client to preterm labor.
8. A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect?
Saturation of one perineal pad every 15 min
The nurse should not expect saturation of one perineal pad every 15 min as this indicates postpartum hemorrhage, which could lead to
hypovolemic shock.
Fundus 2 cm above the umbilicus
At 32 hr postpartum, the client's fundus should be 1 to 2 cm below the umbilicus. The fundus should descend 1 cm per day after birth.
Temperature of 39° C (102.2° F)
The nurse should identify that a temperature higher than 38° C (100.4° F) after the first 24 hr can indicate infection in a client who is 32
hr postpartum.
Urine output of 3,000 mL in 24 hr
The nurse should expect postpartum diuresis to begin approximately 12 hr after delivery. Therefore, a urine output of 3,000 mL in 24
hr is an expected finding for this client.
9. A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should
the nurse report to the provider?
Calcium 9.2 mg/dL
The nurse should identify that a calcium level of 9.2 mg/dL is within the expected reference range of 7.6 to 10.4 mg/dL for a newborn.
Heart rate 160/min
The nurse should identify that a heart rate of 160/min is within the expected reference range of 110 to 160/min for a newborn. A heart
rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn.
Blood glucose 28 mg/dL
The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 30 to 60 mg/dL for a newborn.
Therefore, the nurse should report this finding to the provider.
Axillary temperature 36.5 C(97.7 F)
The nurse should identify that a temperature for a healthy newborn averages 37 C (98.6 F), with a range of 36.5C to 37.5 C (97.7F to
99.5 F).
10. A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify
as an indication of a potential complication of pregnancy?
