CMS Maternal Newborn Practice 2020 A
Already Passed
A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse report to the provider?
✔✔Blurred vision - indication of preeclampsia
Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr, leg cramps
A nurse is caring or a newborn who is receiving phototherapy. Which of the following actions
should the nurse take? ✔✔Place an opaque mask over the newborn's eyes - to prevent damage to
the retinas
- Should remove mask for feedings
DO NOT apply a thin layer of lotion to the newborn's skin
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
Occurs due to the breakdown of fat secondary to malnutrition or starvation
,Tachycardia and tachypnea due to dehydration
A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling
efforts. Which of the following neonatal data collection tools should the nurse expect to
complete? ✔✔Neonatal Abstinence Scoring System: exhibiting opioid withdrawal
Additional manifestations: restlessness, tremors, increased muscle tone, and an exaggerated
Moro reflex
- Apgar score: heart rate, respiratory rate, muscle tone, reflex irritability and skin color
- Newborn Hearing Screen should be completed before the newborn is discharged from the
hospital
- Critical Congenital Heart Disease screen should be completed 24- 28 hours following birth and
before the newborn is discharged from the hospital
A nurse is assisting in the care of a newborn immediately following birth. Which of the
following images should the nurse identify as an indication that the newborn has a
myelomeningocele? ✔✔Occurs when the neural tube fails to close, and the meninges and spinal
cord herniate
Occurs in the lumbar area and may be covered by a thin membranous sac
,- Exstrophy of the bladder; occurs from abnormal development of the abdominal wall, symphysis
pubis and bladder ; visible in the suprapubic area and requires surgical intervention soon after
birth
- Omphalocel: occurs when abdominal organs herniate through the umbilical ring at the base of
the umbilical cord
- Cephalohematoma; collection of blood between the skull bone and its covering, the periosteum.
A cephalohematoma does not cross the suture lines of the newborn's skull and will
spontaneously resolve in 2-8 weeks
A nurse is collecting data from a newborn who is 8hr old. Which of the following findings
should the nurse report to the provider? ✔✔Apical heart rate of 90/min while crying - normal
range 110 - 160 for a newborn, heart rate of 80-100/min while asleep and up to 180/min while
crying
- Apneic episode of 20 seconds or less - normal; newborns respirations are normally shallow and
irregular
- Positive moro reflex present from birth up to 8 weeks
- Vernix in the skin folds - normal
A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn.
The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal
, edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the
right. Which of the following actions is the nurse's priority?
a. administer analgesics
b. apply an ice pack to the perineum
c. assist the client with breastfeeding
d. help the client ambulate to the toilet ✔✔d. help the client ambulate to the toilet
The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the
priority intervention by the nurse is to assist the client to urinate and completely empty the
bladder, which will allow the uterus to contract.
A nurse is reinforcing teaching with a client who is at 20 wks of gestation and has gestational
diabetes mellitus. Which of the following information should the nurse include in the teaching?
a. exercise before meals
b. consume at least 2,000 cal/day
c. avoid consuming an evening snack
d. maintain a fasting blood glucose of 110 to 120 mg/dL ✔✔b. consume at least 2,000 cal/day
Already Passed
A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse report to the provider?
✔✔Blurred vision - indication of preeclampsia
Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr, leg cramps
A nurse is caring or a newborn who is receiving phototherapy. Which of the following actions
should the nurse take? ✔✔Place an opaque mask over the newborn's eyes - to prevent damage to
the retinas
- Should remove mask for feedings
DO NOT apply a thin layer of lotion to the newborn's skin
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
Occurs due to the breakdown of fat secondary to malnutrition or starvation
,Tachycardia and tachypnea due to dehydration
A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling
efforts. Which of the following neonatal data collection tools should the nurse expect to
complete? ✔✔Neonatal Abstinence Scoring System: exhibiting opioid withdrawal
Additional manifestations: restlessness, tremors, increased muscle tone, and an exaggerated
Moro reflex
- Apgar score: heart rate, respiratory rate, muscle tone, reflex irritability and skin color
- Newborn Hearing Screen should be completed before the newborn is discharged from the
hospital
- Critical Congenital Heart Disease screen should be completed 24- 28 hours following birth and
before the newborn is discharged from the hospital
A nurse is assisting in the care of a newborn immediately following birth. Which of the
following images should the nurse identify as an indication that the newborn has a
myelomeningocele? ✔✔Occurs when the neural tube fails to close, and the meninges and spinal
cord herniate
Occurs in the lumbar area and may be covered by a thin membranous sac
,- Exstrophy of the bladder; occurs from abnormal development of the abdominal wall, symphysis
pubis and bladder ; visible in the suprapubic area and requires surgical intervention soon after
birth
- Omphalocel: occurs when abdominal organs herniate through the umbilical ring at the base of
the umbilical cord
- Cephalohematoma; collection of blood between the skull bone and its covering, the periosteum.
A cephalohematoma does not cross the suture lines of the newborn's skull and will
spontaneously resolve in 2-8 weeks
A nurse is collecting data from a newborn who is 8hr old. Which of the following findings
should the nurse report to the provider? ✔✔Apical heart rate of 90/min while crying - normal
range 110 - 160 for a newborn, heart rate of 80-100/min while asleep and up to 180/min while
crying
- Apneic episode of 20 seconds or less - normal; newborns respirations are normally shallow and
irregular
- Positive moro reflex present from birth up to 8 weeks
- Vernix in the skin folds - normal
A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn.
The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal
, edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the
right. Which of the following actions is the nurse's priority?
a. administer analgesics
b. apply an ice pack to the perineum
c. assist the client with breastfeeding
d. help the client ambulate to the toilet ✔✔d. help the client ambulate to the toilet
The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the
priority intervention by the nurse is to assist the client to urinate and completely empty the
bladder, which will allow the uterus to contract.
A nurse is reinforcing teaching with a client who is at 20 wks of gestation and has gestational
diabetes mellitus. Which of the following information should the nurse include in the teaching?
a. exercise before meals
b. consume at least 2,000 cal/day
c. avoid consuming an evening snack
d. maintain a fasting blood glucose of 110 to 120 mg/dL ✔✔b. consume at least 2,000 cal/day
