Maternal newborn online practice 2019 A with
rationale
A nurse is assessing a client who has gestational diabetes mellitus and is
experiencing hyperglycemia. Which of the following findings should the nurse
expect?
-Reports increased urinary output
Rationale: Increased urinary output, n/v, reports of thirst, abd. pain, constipation,
drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations
include weak rapid pulse, fruity breath, urine positive for sugar and acetone, and a
blood glucose level greater than 200 mg/dL.
A nurse is caring for a client who is at 22 weeks gestation and is HIV positive.
Which of the following actions should the nurse take?
-Report the clients condition to the health department
Rationale: HIV is one of the conditions on the list of Nationally Notifiable Infectious
Conditions that is required to be reported.
A nurse is providing teaching for a client who has a new prescription for
combined oral contraceptives. Which of the following findings should the nurse
include as an adverse effect of this medication?
-Depression
Rationale: The nurse should instruct the client that depression is a common adverse
effect of combined oral contraceptives. Other common AE of the medication include
amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast
tenderness.
A nurse if providing teaching to a client who is at 40 weeks of gestation and has a
new prescription for misoprostol. Which of the following instructions should the
nurse include in the teaching?
-"I can administer oxytocin 4 hours after the insertion of the medication."
Rationale: The nurse can administer oxytocin no sooner than 4 hours after the last dose
of misoprostol. Oxytocin can be administered following misprostol for clients who have
cervical ripening and have not begun labor.
A nurse is caring for a prenatal client who has parvovirus B19 (5th disease).
Which of the following actions should the nurse take?
- Schedule an ultrasound examination
Rationale: to monitor fetus during the pregnancy to detect the possible development of
fetyal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction,
fetal anemia, or stillbirth.
A nurse is preparing to collect a blood speciman from a newborn via a heel stick.
Which of the following techniques should the nurse use to help minimize the pain
of the procedure for the newborn?
, -Place the newborn skin to skin on the mother's chest
-Rationale:Place the newborn skin to skin on the mother's chest is an effective
technique to significantly decrease the newborn's pain level and anxiety. The nurse
should implement this technique before, during, and after the procedure.
A nurse is performing a vaginal examination on a client who is in labor and
observes the umbilical cord protruding from the vagina. After calling for
assistance, which of the following actions should the nurse take?
- insert two gloved fingers into the vagina and apply upward pressure to the presenting
part.
Rationale: exerting upward pressure onto the presenting part to relieve umbilical cord
compression and increase oxygenation to the fetus.
A nurse is caring for a client who is at 24 weeks gestation and has a suspected
placental abruption. Which of the following lab tests should the nurse expect the
provider to prescribe?
-Kleihaurer-Betke test
Rationale: test is performed on a client who has suspected placental abruption to
determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-
(D) immune globulin therapy should be administered to a client who is Rh-negative.
A nurse is admitting a client who is in labor. The client admits to recent cocaine
use. For which of the following complications should the nurse assess?
-Abruptio placenta
Rationale: Cocaine use increases the risk for vasoconstriction and possible abruptio
placenta.
A nurse is assessing a client who has severe preeclampsia. Which of the
following manifestations should the nurse expect?
-Blurred vision
Rationale: The nurse should identify that a client who has severe preeclampsia can
have arteriolar vasospasms and decreased blood flow to the retina which can lead to
visual disturbances, such as blurred vision, double vision, or dark spots in the visual
field.
A nurse is providing education about family bonding to parents who recently
adopted a newborn. The nurse should make which of the following suggestions
to aid the family's 7 year old child in accepting the new family member?
-Obtain a gift from the newborn to present to the sibling
Rationale: Presenting a gift from the newborn to the sibling is a strategy to facilitate a
school-age sibling's acceptance of a new family member. This ensures the sibling
doesnt feel left out and that they understand their role in the family.
A nurse is assessing a client who is receiving morphine via IV bolus for pain
follow a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the
following medications should the nurse administer?
rationale
A nurse is assessing a client who has gestational diabetes mellitus and is
experiencing hyperglycemia. Which of the following findings should the nurse
expect?
-Reports increased urinary output
Rationale: Increased urinary output, n/v, reports of thirst, abd. pain, constipation,
drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations
include weak rapid pulse, fruity breath, urine positive for sugar and acetone, and a
blood glucose level greater than 200 mg/dL.
A nurse is caring for a client who is at 22 weeks gestation and is HIV positive.
Which of the following actions should the nurse take?
-Report the clients condition to the health department
Rationale: HIV is one of the conditions on the list of Nationally Notifiable Infectious
Conditions that is required to be reported.
A nurse is providing teaching for a client who has a new prescription for
combined oral contraceptives. Which of the following findings should the nurse
include as an adverse effect of this medication?
-Depression
Rationale: The nurse should instruct the client that depression is a common adverse
effect of combined oral contraceptives. Other common AE of the medication include
amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast
tenderness.
A nurse if providing teaching to a client who is at 40 weeks of gestation and has a
new prescription for misoprostol. Which of the following instructions should the
nurse include in the teaching?
-"I can administer oxytocin 4 hours after the insertion of the medication."
Rationale: The nurse can administer oxytocin no sooner than 4 hours after the last dose
of misoprostol. Oxytocin can be administered following misprostol for clients who have
cervical ripening and have not begun labor.
A nurse is caring for a prenatal client who has parvovirus B19 (5th disease).
Which of the following actions should the nurse take?
- Schedule an ultrasound examination
Rationale: to monitor fetus during the pregnancy to detect the possible development of
fetyal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction,
fetal anemia, or stillbirth.
A nurse is preparing to collect a blood speciman from a newborn via a heel stick.
Which of the following techniques should the nurse use to help minimize the pain
of the procedure for the newborn?
, -Place the newborn skin to skin on the mother's chest
-Rationale:Place the newborn skin to skin on the mother's chest is an effective
technique to significantly decrease the newborn's pain level and anxiety. The nurse
should implement this technique before, during, and after the procedure.
A nurse is performing a vaginal examination on a client who is in labor and
observes the umbilical cord protruding from the vagina. After calling for
assistance, which of the following actions should the nurse take?
- insert two gloved fingers into the vagina and apply upward pressure to the presenting
part.
Rationale: exerting upward pressure onto the presenting part to relieve umbilical cord
compression and increase oxygenation to the fetus.
A nurse is caring for a client who is at 24 weeks gestation and has a suspected
placental abruption. Which of the following lab tests should the nurse expect the
provider to prescribe?
-Kleihaurer-Betke test
Rationale: test is performed on a client who has suspected placental abruption to
determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-
(D) immune globulin therapy should be administered to a client who is Rh-negative.
A nurse is admitting a client who is in labor. The client admits to recent cocaine
use. For which of the following complications should the nurse assess?
-Abruptio placenta
Rationale: Cocaine use increases the risk for vasoconstriction and possible abruptio
placenta.
A nurse is assessing a client who has severe preeclampsia. Which of the
following manifestations should the nurse expect?
-Blurred vision
Rationale: The nurse should identify that a client who has severe preeclampsia can
have arteriolar vasospasms and decreased blood flow to the retina which can lead to
visual disturbances, such as blurred vision, double vision, or dark spots in the visual
field.
A nurse is providing education about family bonding to parents who recently
adopted a newborn. The nurse should make which of the following suggestions
to aid the family's 7 year old child in accepting the new family member?
-Obtain a gift from the newborn to present to the sibling
Rationale: Presenting a gift from the newborn to the sibling is a strategy to facilitate a
school-age sibling's acceptance of a new family member. This ensures the sibling
doesnt feel left out and that they understand their role in the family.
A nurse is assessing a client who is receiving morphine via IV bolus for pain
follow a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the
following medications should the nurse administer?
