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RN Maternal Newborn 2023
Total Questions : 63
Showing 10 questions, Sign in for more- 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
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.
Explanation
- 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.
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.
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.
- 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.
Which of the following findings should the nurse report to the provider?
Select all that apply
- 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
Which of the following assessment findings requires immediate follow-up)
Select all that apply
- 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
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.
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 worsening condition
Explanation: A respiratory rate of 70/min in a newborn is higher than the normal range (30-60 breaths per minute). This could indicate respiratory distress, infection, or other complications, requiring further assessment.
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.
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?
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?
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?
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?
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?
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