RN Maternal Newborn Online Practice with Verified Answers
- Uterine contractions.
The client is experiencing regular uterine
contractions and cervical change, which
are indicators of preterm labor; there-
fore, the nurse should notify the provider
about this finding.
- Gestational age.
The client is at 32 weeks of gestation
and is experiencing regular uterine con-
tractions and cervical dilation, which in-
A nurse is caring for a client who is preg-
dicates that the client is in preterm la-
nant in an antepartum clinic. Which of
bor; therefore, the nurse should notify the
the following findings should the nurse
provider about this finding.
report to the provider?
- Vaginal examination.
The client's cervix is dilated to 2 cm and
is 50% effaced, which indicate the client
is in preterm labor; therefore, the nurse
should notify the provider about this find-
ing.
The client's blood pressure is within the
expected reference range . Blood pres-
sure 130/70 mm Hg? what is normal.
Report the client's condition to the local
health department.
Rationale:
The nurse should report the condition to
the local health department. HIV is one
A nurse is caring for a client who is at 22 of the conditions on the list of National-
weeks of gestation and is HIV positive. ly Notifiable Infectious Conditions that is
Which of the following actions should the required to be reported.
nurse take?
Other considerations:
The nurse should tell the client that treat-
ment for HIV will be during the pre-
natal and perinatal periods. Treatment
with antiretroviral prophylaxis such as zi-
dovudine, triple-drug antiretroviral thera-
, RN Maternal Newborn Online Practice with Verified Answers
py (ART), or highly active antiretroviral
therapy (HAART) during pregnancy have
been reported to decrease the transmis-
sion of the virus to the newborn.
Decreased platelet count
Rationale:
A client who has ITP has an autoimmune
A nurse is assessing a client who is post- response that results in a decreased
partum and has idiopathic thrombocy- platelet count.
topenia purpura (ITP). Which of the fol-
lowing findings should the nurse expect? Other considerations:
- An increased ESR is an indication of
chronic renal failure.
- An increased WBC is an indication of
infection.
Emotional lability
Rationale:
A nurse in the antepartum clinic is as- The nurse should recognize and in-
sessing a client's adaptation to pregnan- terpret the client's statement as an
cy. The client states that they are "happy indication of emotional lability. Many
one minute and crying the next." The clients experience rapid and unpre-
nurse should interpret the client's state- dictable changes in mood during preg-
ment as an indication of which of the nancy. Intense hormonal changes may
following? be responsible for mood changes that
occur during pregnancy. Tears and anger
alternate with feelings of joy or cheerful-
ness for little or no reason.
Vomiting
A nurse is assessing the newborn of a Rationale:
client who took a selective serotonin re-
Expected manifestations associated with
uptake inhibitor (SSRI) during pregnan-
fetal exposure to SSRIs include irritabili-
cy. Which of the following manifestations
ty, agitation, tremors, diarrhea, and vom-
should the nurse identify as an indication
iting. These manifestations typically last
of withdrawal from an SSRI?
2 days.
,RN Maternal Newborn Online Practice with Verified Answers
Manifestations of fetal exposure to SS-
RIs. include: Low birth weight, Hypo-
glycemia, Tachypnea.
A newborn who is 18 hr old and has an
axillary temperature of 37.7° C (99.9° F)
Rationale
An axillary temperature greater than
37.5° C (99.5° F) is above the expected
reference range of 36.5 - 37.5 ° C for a
newborn and can be an indication of sep-
sis. Therefore, the nurse should report
this finding to the provider.
other considerations:
A nurse is assessing four newborns.
- A newborn should pass the first meco-
Which of the following findings should
nium stool within the first 24 to 48 hr fol-
the nurse report to the provider?
lowing birth. Failure to pass a meconium
stool can indicate a bowel obstruction or
congenital disorder.
- Pink-tinged urine is an indication of uric
acid crystals and is an expected finding
for a newborn during the first week fol-
lowing birth.
- Erythema toxicum is a transient rash
that can appear anywhere on a new-
born's body during the first 24 to 72 hr
following birth and can last up to 3 weeks.
This finding requires no treatment.
FHR 152/min
Rationale:
The expected range for the FHR is
110/min to 160/min. The FHR is higher
earlier in gestation with an average of
approximately 160/min at 20 weeks of
gestation.
, RN Maternal Newborn Online Practice with Verified Answers
Other considerations:
-The nurse should expect the client's
DTR to be 2+
- From gestational weeks 18 to 32, the
A nurse is performing a routine assess- height of the fundus is approximately
ment on a client who is at 18 weeks of equal to the number of weeks of gesta-
gestation. Which of the following findings tion plus or minus 2 cm. Therefore, the
should the nurse expect? nurse should expect the fundal height for
this client to be 16 to 20 cm.
- An elevated blood pressure greater or
equal to 140/90, may be an indication of
preeclampsia.
Lays the newborn across their lap and
gently sways
Rationale:
This is a correct technique for quieting
a newborn. This tactile stimulation pro-
motes a sense of security for the new-
born.
Other considerations:
A nurse is observing a new guardian car- - The guardian should place the infant in
ing for their crying newborn who is bottle the supine position, not a prone position,
feeding. Which of the following actions by in the bassinet or crib because of the risk
the guardian should the nurse recognize of sudden infant death syndrome.
as a positive parenting behavior? - Rice cereal should not be added to
the bottle of a newborn because solids
should not be introduced until 4 to 6
months of age.
- Pacifiers may be used for a newborn
who needs extra sucking for self-sooth-
ing. However, formula should not be
placed on the tip of the pacifier because
the newborn might become accustomed
to it and refuse to take the pacifier in the
future without added supplement.
- Uterine contractions.
The client is experiencing regular uterine
contractions and cervical change, which
are indicators of preterm labor; there-
fore, the nurse should notify the provider
about this finding.
- Gestational age.
The client is at 32 weeks of gestation
and is experiencing regular uterine con-
tractions and cervical dilation, which in-
A nurse is caring for a client who is preg-
dicates that the client is in preterm la-
nant in an antepartum clinic. Which of
bor; therefore, the nurse should notify the
the following findings should the nurse
provider about this finding.
report to the provider?
- Vaginal examination.
The client's cervix is dilated to 2 cm and
is 50% effaced, which indicate the client
is in preterm labor; therefore, the nurse
should notify the provider about this find-
ing.
The client's blood pressure is within the
expected reference range . Blood pres-
sure 130/70 mm Hg? what is normal.
Report the client's condition to the local
health department.
Rationale:
The nurse should report the condition to
the local health department. HIV is one
A nurse is caring for a client who is at 22 of the conditions on the list of National-
weeks of gestation and is HIV positive. ly Notifiable Infectious Conditions that is
Which of the following actions should the required to be reported.
nurse take?
Other considerations:
The nurse should tell the client that treat-
ment for HIV will be during the pre-
natal and perinatal periods. Treatment
with antiretroviral prophylaxis such as zi-
dovudine, triple-drug antiretroviral thera-
, RN Maternal Newborn Online Practice with Verified Answers
py (ART), or highly active antiretroviral
therapy (HAART) during pregnancy have
been reported to decrease the transmis-
sion of the virus to the newborn.
Decreased platelet count
Rationale:
A client who has ITP has an autoimmune
A nurse is assessing a client who is post- response that results in a decreased
partum and has idiopathic thrombocy- platelet count.
topenia purpura (ITP). Which of the fol-
lowing findings should the nurse expect? Other considerations:
- An increased ESR is an indication of
chronic renal failure.
- An increased WBC is an indication of
infection.
Emotional lability
Rationale:
A nurse in the antepartum clinic is as- The nurse should recognize and in-
sessing a client's adaptation to pregnan- terpret the client's statement as an
cy. The client states that they are "happy indication of emotional lability. Many
one minute and crying the next." The clients experience rapid and unpre-
nurse should interpret the client's state- dictable changes in mood during preg-
ment as an indication of which of the nancy. Intense hormonal changes may
following? be responsible for mood changes that
occur during pregnancy. Tears and anger
alternate with feelings of joy or cheerful-
ness for little or no reason.
Vomiting
A nurse is assessing the newborn of a Rationale:
client who took a selective serotonin re-
Expected manifestations associated with
uptake inhibitor (SSRI) during pregnan-
fetal exposure to SSRIs include irritabili-
cy. Which of the following manifestations
ty, agitation, tremors, diarrhea, and vom-
should the nurse identify as an indication
iting. These manifestations typically last
of withdrawal from an SSRI?
2 days.
,RN Maternal Newborn Online Practice with Verified Answers
Manifestations of fetal exposure to SS-
RIs. include: Low birth weight, Hypo-
glycemia, Tachypnea.
A newborn who is 18 hr old and has an
axillary temperature of 37.7° C (99.9° F)
Rationale
An axillary temperature greater than
37.5° C (99.5° F) is above the expected
reference range of 36.5 - 37.5 ° C for a
newborn and can be an indication of sep-
sis. Therefore, the nurse should report
this finding to the provider.
other considerations:
A nurse is assessing four newborns.
- A newborn should pass the first meco-
Which of the following findings should
nium stool within the first 24 to 48 hr fol-
the nurse report to the provider?
lowing birth. Failure to pass a meconium
stool can indicate a bowel obstruction or
congenital disorder.
- Pink-tinged urine is an indication of uric
acid crystals and is an expected finding
for a newborn during the first week fol-
lowing birth.
- Erythema toxicum is a transient rash
that can appear anywhere on a new-
born's body during the first 24 to 72 hr
following birth and can last up to 3 weeks.
This finding requires no treatment.
FHR 152/min
Rationale:
The expected range for the FHR is
110/min to 160/min. The FHR is higher
earlier in gestation with an average of
approximately 160/min at 20 weeks of
gestation.
, RN Maternal Newborn Online Practice with Verified Answers
Other considerations:
-The nurse should expect the client's
DTR to be 2+
- From gestational weeks 18 to 32, the
A nurse is performing a routine assess- height of the fundus is approximately
ment on a client who is at 18 weeks of equal to the number of weeks of gesta-
gestation. Which of the following findings tion plus or minus 2 cm. Therefore, the
should the nurse expect? nurse should expect the fundal height for
this client to be 16 to 20 cm.
- An elevated blood pressure greater or
equal to 140/90, may be an indication of
preeclampsia.
Lays the newborn across their lap and
gently sways
Rationale:
This is a correct technique for quieting
a newborn. This tactile stimulation pro-
motes a sense of security for the new-
born.
Other considerations:
A nurse is observing a new guardian car- - The guardian should place the infant in
ing for their crying newborn who is bottle the supine position, not a prone position,
feeding. Which of the following actions by in the bassinet or crib because of the risk
the guardian should the nurse recognize of sudden infant death syndrome.
as a positive parenting behavior? - Rice cereal should not be added to
the bottle of a newborn because solids
should not be introduced until 4 to 6
months of age.
- Pacifiers may be used for a newborn
who needs extra sucking for self-sooth-
ing. However, formula should not be
placed on the tip of the pacifier because
the newborn might become accustomed
to it and refuse to take the pacifier in the
future without added supplement.
