Maternal Newborn Care

1

100

A nurse is caring for a client who suspects she is pregnant and has presumptive signs of pregnancy. Which of the following findings should the nurse expect the client to report? (Select all that apply)

A. Amenorrhea

B. Goodell sign

C. Ballottement 

D. Nausea and vomiting

E. Quickening

Answer:

A, D, E

Goodell sign objective or probable sign of softening of the cervical tip

Ballottement sign objective sign of rebound of unengaged fetus

200

A nurse is caring for a client at term gestation who is in labor and anticipating simple vaginal delivery. Which of the following is an example of a warning sign of potential complications? (select all that apply)

A. Maternal temperature less than 98.6 degrees

B. Meconium-stained amniotic fluid

C. Fetal heart rate of 120 bpm

D. Foul-smelling vaginal discharge

E. Moderate fetal heart rate variability on fetal heart monitoring

Answers: B and D

300

A nurse is caring for a client at 38 weeks gestation who reports severe sudden abdominal "ripping" pain when receiving an oxytocin infusion during labor. The client's heart rate is 130 bpm, and she is tachypneic. The fetal heart rate monitor reveals minimal variability and bradycardia. Which of the following tasks does the nurse anticipate? 

A. Place the client in the knee-to-chest position

B. Prepare for immediate cesarean delivery

C. Prepare for forceps delivery

D. Prepare to suction the neonate with an endotracheal tube below the vocal cords before first attempts at breathing

Answer B

The description is for a life-threatening uterine rupture. 

2

100

The nurse is caring for a client ten hours after a cesarean delivery of a term infant. All of the findings would lead the nurse to suspect the client is developing disseminated intravascular coagulation (DIC) EXCEPT:

A. Bright red blood from an incision

B. Petechiae under the blood pressure cuff

C. Temperature of 98.2 degrees Fahrenheit

D. Platelet count of 75,000/mm3

Answer C

200

A nurse is counseling a 45-year-old pregnant woman regarding the risks associated with amniocentesis. Which of the following is NOT a risk associated with this procedure?

A. Infection

B. Miscarriage

C. Leakage of amniotic fluid

D. Seizure

E. Vaginal bleeding

Answer: D. Seizure

300

A nurse is teaching a client who is pregnant about the variables that are scored during a biophysical profile (BPP). Which of the following variables should the nurse include? (Select all that apply)

A. Fetal weight

B. Fetal breathing movement

C. Fetal tone

D. Fetal station

E. Amniotic fluid volume

Answer: B, C, E

3

100

A nurse is caring for a client with pre-eclampsia who has a prescription for an infusion of magnesium sulfate. Which of the following actions will be implemented by the nurse? (Select all that apply)

A. Dilute IV solutions to <10%

B. Monitor urine output

C. Assess deep tendon reflexes

D. Monitor pupillary response

E. Monitor oxygen saturation continuously 

Answers: B and C

remember to monitor BP and pulse every 10 to 15 minutes, respiratory rate, deep tendon reflexes, and urine output in clients receiving magnesium.

IV solutions are diluted to 20%, or less and cardiac monitoring is indicated if the magnesium rate is greater than 20 mEq/5 hours. 

200

A nurse cares for a new client who reports a positive home pregnancy test. She is seen in the clinic on January 6, and her last menstrual period was on October 6. Which of the following does the nurse expect? (Select all that apply)

A. Fetal heart rate can be detected by Doppler

B. The client will report fetal movement

C. Dysuria is common

D. The expected date of delivery by Naegele's rule is July 13

E. Fundus height should be 20 cm above the symphesis pubis. 

Answers: A and D

Naegele's rule subtracts 3 months from the date of LMP and add 7 days. FHR may be detected by Doppler beginning from 10 to 12 weeks gestation. 

300

A nurse has been assigned to care for a pregnant client who has been diagnosed with HELLP syndrome. Which of the following nursing interventions is most important when caring for this client?

A. Palpate the abdomen every 4 hours to check for masses or bleeding

B. Increase IV fluids to avoid hypotension and shock

C. Administer magnesium sulfate as ordered

D. Keep the client in a supine position with the legs elevated

Answer: C. 

we administer magnesium sulfate to reduce the risk of seizures for the client. 

4

100

A nurse is preparing to perform a non-stress test. Which position would the nurse recommend that the client be placed in?

A. Left lateral position

B. Supine position

C. Prone position

D. High Fowler's position

Answer A

200

Which of the following increases the risk of postpartum hemorrhage? (Select all that apply)

A. Pregnancy induced hypertension

B. Placental abruption

C. First birth

D. Fetal demise

E. Preterm delivery

Answers: A, B, D

300

In what order should the nurse plan to evaluate the following clients?

1. A 25-year-old who had an uncomplicated vaginal delivery 10 hours ago is complaining about mild abdominal cramping.

2. A 30-year-old who had an uncomplicated vaginal delivery 4 hours ago and has soaked 5 pads since delivery

3. An 18-year-old who had a cesarean section 36 hours ago and is complaining of breast pain

4. A 20-year-old who had a cesarean section six hours ago who is receiving IV magnesium sulfate for preeclampsia and has stable vital signs and a headache

2. Soaked 5 pads

4. Preeclampsia client

3. Breast pain client

1. abdominal cramping client

Remember postpartum hemorrhage is defined as soaking at least one pad each hour after delievery.