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RN Maternal Newborn 2023

Total Questions : 63

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Question 1:
  • Vacuum-assisted vaginal birth
  • Maternal history of positive group B streptococcus B-hemolytic Mother received two doses of ampicillin IV bolus during labor

A nurse is caring for a newborn Immediately following birth.

Exhibit 1

Exhibits

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is Improving, or an Indication that the client's condition is worsening.

Answer and Explanation

Explanation

a. Muscle tone: flaccid Interpretation: This finding suggests a lack of muscle tone, which could be concerning. It may indicate a neurological issue or possible birth trauma. Interpretation: Indication that the client's condition is worsening. b. Respiration effort: good cry Interpretation: A good cry indicates that the newborn is able to breathe properly and is responsive. Interpretation: Indication that the client's condition is improving. c. Reflex irritability: cry Interpretation: The newborn's ability to cry in response to stimuli is a positive sign of reflex irritability and neurological function. Interpretation: Indication that the client's condition is improving. d. Color consistent with genetic background Interpretation: This suggests that the newborn's skin color is within the range typical for their genetic background. Interpretation: Unrelated to the diagnosis. e. Heart rate 140/min Interpretation: A heart rate of 140 beats per minute is within the normal range for a newborn. Interpretation: Unrelated to the diagnosis. f. Axillary temperature 36.3°C (97.4°F) Interpretation: A temperature of 36.3°C (97.4°F) is within the normal range for a newborn. Interpretation: Unrelated to the diagnosis.

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Question 2:
  • Gravida 1 with a multifetal pregnancy
  • Admitted with excessive vomiting for the past 48 hr and weight loss of 2.3 kg (5lb) over 2 days.

A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

Exhibits


The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Answer and Explanation

Explanation

For the findings 24 hours later, the nurse should interpret them as follows:

Urinary output: 40 ml/hr

Interpretation: Sign of potential worsening condition

Explanation: A urinary output of 40 ml/hr is concerning and indicates potential dehydration. It is a sign of potential worsening of the client's condition, as it suggests inadequate fluid intake or ongoing fluid losses.

3+ ketones

Interpretation: Sign of potential worsening condition

Explanation: The presence of 3+ ketones in the urine suggests ongoing ketosis, which can occur in hyperemesis gravidarum due to starvation and the breakdown of fats for energy. It is a sign of potential worsening of the client's nutritional status.

Heart rate: 100/min

Interpretation: Sign of potential improvement

Explanation: A heart rate of 100/min is within the normal range. It can be interpreted as a sign of potential improvement, indicating that the client's cardiovascular system is maintaining an appropriate heart rate.

WBC count: 10,000/mm3

Interpretation: Unrelated to diagnosis

Explanation: The WBC count within the normal range (10,000/mm3) is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.

Urine specific gravity: 1.050

Interpretation: Sign of potential worsening condition

Explanation: A urine specific gravity of 1.050 is elevated and indicates concentrated urine. This finding is a sign of potential worsening of the client's dehydration status.

Urine pH: 5

Interpretation: Unrelated to diagnosis

Explanation: The urine pH of 5 is within the normal range and is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.


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Question 3:
  • Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation.
  • Apgar 9/9 at 5-minute score.
  • Breastfeeding 3 to 4 times per day.
  • Newborn has voided once since birth and has not passed meconium stool since birth

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36hr old.

Exhibits

Which of the following findings should the nurse report to the provider?

Select all that apply

Answer and Explanation

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Question 4:
  • Fundal height: 33cm
  • Fetal heart rate: 174/min
  • Moderate amount of bright red vaginal bleeding
  • Abdomen soft to palpation and without tenderness

A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa

Exhibits

Which of the following assessment findings requires immediate follow-up)

Select all that apply

Answer and Explanation

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Question 5:
  • Maternal histury of opioid use during pregnancy.
  • Precipitous vaginal birth at 39 eveeks of gestation

A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Answer and Explanation

Explanation

Transient strabismus:

Interpretation: Unrelated to diagnosis

Explanation: Transient strabismus (crossed eyes) is not necessarily related to the maternal history of opioid use or precipitous birth. It is a common finding in newborns and often resolves on its own without intervention.

Respiratory rate 70/min:

Interpretation: Sign of potential improvement

Explanation: A respiratory rate of 70/min is within the normal range for a newborn. This finding is a sign of potential improvement as it indicates that the newborn's respiratory function is within an expected range.

Continuous high-pitched cry:

Interpretation: Sign of potential worsening condition

Explanation: A continuous high-pitched cry can be a sign of potential distress or discomfort in a newborn. It may be associated with various conditions, including withdrawal symptoms related to maternal opioid use during pregnancy. This finding warrants further assessment.

Regurgitation:

Interpretation: Unrelated to diagnosis

Explanation: Regurgitation (spitting up) is a common occurrence in newborns and is not necessarily related to the maternal history of opioid use. It is often a normal physiological process in infants.

Loose stools:

Interpretation: Unrelated to diagnosis

Explanation: Loose stools can be a normal finding in newborns and may not be directly related to the maternal history of opioid use. It is not necessarily indicative of a worsening condition in this context.


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Question 6:

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Answer and Explanation

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Question 7:

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Answer and Explanation

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Question 8:

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

Answer and Explanation

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Question 9:

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal message. Which of the following actions should the nurse take?

Answer and Explanation

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Question 10:

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

Answer and Explanation

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Question 11:

A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

Answer and Explanation

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Question 12:

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

Answer and Explanation

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Question 13:

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

Answer and Explanation

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Question 14:

A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?

Answer and Explanation

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Question 15:

A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

Answer and Explanation

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Question 16:

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

Answer and Explanation

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Question 17:

A nurse is providing teaching to a new parent about findings that require notification of the newborn's provider. Which of the following newborn clinical manifestations should the nurse include in the teaching?

Answer and Explanation

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Question 18:

A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following should the nurse include?

Answer and Explanation

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Question 19:

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

Answer and Explanation

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Question 20:

A nurse is caring for a client who is in labor and has spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina. After calling for help, which of the following actions should the nurse take first?

Answer and Explanation

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Question 21:

A nurse is reviewing the history of a client who is pregnant. Which of the following clinical data indicates the client is at risk for preterm delivery?

Answer and Explanation

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Question 22:

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Answer and Explanation

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Question 23:

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

Answer and Explanation

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Question 24:

A nurse in planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Answer and Explanation

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Question 25:

A nurse in a clinic is caring for an adolescent client who requests a prescription for birth control. Which of the following questions should the nurse ask?

Answer and Explanation

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