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Maternal Newborn Assessment
A nurse is performing a vaginal exam on a client who is in active labor.
The nurse notes the umbilical cord protruding through the cervix. Which
of the following actions should the nurse take?
Administer oxytocin to the client via intravenous
infusion. Apply oxygen at 2 L/min via nasal
cannula.
Prepare for insertion of an intrauterine pressure
catheter. Assist the client into the knee-chest
position.
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid
withdrawals. Which of the following findings should the nurse expect?
Hypotonicity
Moderate tremors of the
extremities Axillary temperature
36.1° C (96.9° F) Excessive
sleeping
A nurse is providing teaching about newborn safety to a client who is being
admitted for induction of labor. Which of the following client statements
indicate an understanding of the teaching?
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"I will check the identication badge of anyone who removes my baby from our
room."
"I should include a photo of my baby along with any public birth
announcements to social media."
"I will allow my baby to sleep on the bed in my room when I am in
the shower." "I should expect the nurses to carry my baby in their
arms to the nursery."
A nurse is assessing a client who is at 31 weeks of gestation. Which of the
following findings should the nurse identify as an indication of a potential
prenatal complication?
Periodic tingling of
fingers Absence of
clonus
Leg cramps
Blurred vision
A nurse is reviewing the laboratory results of a newborn who is 24 hr old.
Which of the following findings should the nurse report to the provider?
Hemoglobin 12
g/dL Glucose 50
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mg/dL
Bilirubin 4 mg/dL
Platelets
200,000/mm
A nurse is assessing a newborn who is 48 hr old and has a maternal history
of methadone use during pregnancy. Which of the following manifestations
should the nurse identify as an indication of neonatal abstinence syndrome?
Hyporeactivity
Excessive high-pitched
cry Acrocyanosis
Respiratory rate of 50/min
A nurse is caring for a client who has placenta previa. Which of the
following interventions should the nurse implement for this client?
(Select all that apply.)
Perform a vaginal exam.
Monitor fetal heart rate with an internal fetal
monitor. Frequently assess maternal heart
rate.
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