Maternal newborn online practice 2019 A
with rationale 100% pass
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.
with rationale 100% pass
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.
