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CMS Maternal Newborn Practice 2024-2025 A
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 notify the provider about?
- Answer Blurred vision - sign of preeclampsia Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr, leg cramps
A nurse is caring for a newborn receiving phototherapy. Which of the following nursing action is appropriate? Place an opaque mask over the newborn eyes - prevents damage to the retinas Remove mask during feedings DO NOT apply a thin layer of lotion on the newborn 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? - Answer 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? - Answer 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 being 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 with caring for a newborn directly after birth. Which of the following pictures should the nurse recognize as a sign that this newborn has a myelomeningocele? - Answer Occurs when neural tube does not close, and meninges and spinal cord herniate Occurs in lumbar area and maybe covered by a thin membranous sac Exstrophy of bladder: -abnormal development of abdominal wall, symphysis pubis and bladder. Present in suprapubic area. Visible and requires surgery in neonatal period. Omphalocel: Herniation of abdominal organs through umbilical ring at base of 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 performing data collection on an 8hr old newborn. The following finding should be communicated to the provider: -Answer 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 Within normal limits; normal for newborn's respirations to be shallow and irregular -Moro reflex present positive 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 will be breastfeeding her newborn. The client reports her perineal pain as 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 and deviated 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 - Answer d. help the client ambulate to the toilet
premature labor d. assist in the absorption of other important nutrients - Answer b. prevent some types of birth defects
A nurse is reinforcing discharge teaching regarding methods to prevent engorgement during lactation suppression with a client who is formula-feeding her newborn. Which of the following statements should the nurse identify as indicating that the client has understood the teaching? a. "I will massage my breasts while I am in the shower." b. "I should wear an underwire bra during the day." c. "I should use a breast pump several times a day to relieve discomfort." d. "I will apply cold cabbage leaves to my breasts throughout the day." Answer d "I will apply cold cabbage leaves to my breasts throughout the day."
Should also apply ice packs or cold compresses to her breasts, take mild analgesics and wear a well-fitting and supportive bra.
A nurse is assisting with the care of a client who is at 40 wks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? a. maternal temperature of 37.5 C b. contractions every 3 min c. bloody show d. prolonged deceleration of FHR - Answer d. prolonged deceleration of FHR
Because this may be indicative of an emergent condition such as uterine rupture or prolapse of the umbilical cord.
A client requests that the nurse explain the use of the diaphragm as a contraceptive. Which of the following statements should the nurse include? a. You will need to replace your diaphragm every 2 years a. you can use an oil-based lubricant with your diaphragm
c. you must have a full bladder when you insert diaphragm d. you must remove your diaphragm 1 hour after intercourse to clean it - Answer a. you will need to replace your diaphragm every 2 years
- Avoid the use of baby oil, vaginal lubricants, mineral oil, and body lubricants because these may soften the rubber of the diaphragm and hence reduce its effectiveness. **- Urinate and try to empty the bladder completely before insertion of the diaphragm.
- After intercourse leave the diaphragm in place for at least 6 hr because sperm can still** live in the vagina that length of time.
A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include? a. Eat foods that are served hot b. drink 360 mL (12 oz) of fluids during mealtimes c. consume small meals frequently d. eat a high protein snack before rising from bed-Answer c. take frequent light meals
- Instruct to take 5-6 light meals. The Client should not have an empty stomach because it increases nausea.
- Take High carbohydrate like crackers
- Do not drink liquids with the meal, intake of fluid and food every 2-3 hrs throughout the day
A nurse working on a postpartum unit is caring for a client who is in hypovolemic shock. Which of the following nursing actions would be appropriate for this client? a. Position the client in high-Fowler's position b. Administer terbutaline subcutaneously c. Administer oxygen at 2 L/min via nasal cannula d. Insert an indwelling urinary catheter Answer d. insert an indwelling urinary catheter
- Monitor output closely. Shock from hemorrhage can cause oliguria. Apply oxygen 10 L/min via non-breather face mask Medication administration for oxytocin such as oxytocin or methylergonovine; this will increase uterine contraction. Terbutaline is a tocolytic, which will cause uterine relaxation thus increasing bleeding.
airway. Place so that the newborn is at 45 degree angle.
A nurse is going to administer terbutaline to a client who is in preterm labor. Which of the following routes of administration should the nurse plan to administer? a. intramuscular b. intradermal c. subcutaneous d. topical - Answer c. subcutaneous
Terbutaline relaxes the smooth muscles inhibiting uterine activity. given every 4 hr.
A nurse is reviewing the laboratory results of a 4-hr-old newborn. Which of the following findings should the nurse notify the provider about? a. hemoglobin 20 g/dL b. platelet count 120,000/mm c. Glucose 50 mg/dL d. WBC count 20,000/mm3 - Answer b. platelet count 120,000/mm
Normal range is 150,000 - 300,
- hemoglobin: 14-24 g/dL
- glucose: 30-60 mg/dL
- WBC: 9,000-30,000/mm
A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for nifedipine. Which of the following outcomes does the nurse expect from this medication? a. Fetal lung maturity b. maternal blood glucose control c. cessation of uterine contractions
d. resolution of maternal nausea - Answer c. cessation of uterine contractions
Nifedipine- calcium channel blocker utilized to reduce uterine contractions by replacing smooth muscle of uterus Fetal lung maturity: glucocorticoid -dexamethasone Maternal blood glucose control : oral hypoglycemic agent: glyburide Assist to control blood glucose Resolution of maternal nausea: antiemetic : metoclopramide Decrease maternal nausea
A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? a. 1 cup dried prunes b. 1/2 cup boiled potatoes c. 1/2 cup dried peas d. 1 cup grapes - Answer c. 1/2 cup dried peas
should consume 400 mcg of folate per day
A nurse is reinforcing teaching with a client who has asked about continuing routine exercise during pregnancy. Which of the following responses should the nurse make? a. drink plenty of water after exercising b. lie on your back for 5 mins after exercising c. you should limit exercise to once per week d. increase your exercise intensity as your pregnancy progresses - Answer a. drink plenty of water after exercising
A nurse is caring for a client during the postpartum period. which of the following findings should the nurse expect during the first 24 hr following birth? Select all that apply a. diuresis
manifestation of preeclampsia
A nurse is assisting with collecting data from a newborn who was born 2 hr ago and who has respiratory distress. Which of the following findings should the nurse report to the provider? (Select all that apply.) a. acrocyanosis b. tachypnea c. nasal flaring d. retractions e. expiratory grunting - Answer b, c, d, e
A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching? a. the diaphragm should be removed 2 hours after having intercourse b. I can use water-soluble lubricant when my partner wears a latex condom c. It is okay for me to remove the birth control sponge no more than 2 hours after intercourse d. When I am using the birth control patch, it must be replaced once a month - Response b. I can use water-soluble lubricant when my partner uses a latex condom
- diaphragm must be kept in place at least 6 hr after intercourse Contraceptive sponge is left in place for at least 6 hr after intercourse Contraceptive patch is changed weekly for 3 weeks, followed by 1 week in which the client does not wear the patch
A nurse is caring for a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse recognize as manifestations of magnesium toxicity. Select all that apply. a. hyperreflexia b. decreased respiratory rate c. polyuria d. decreased LOC e. double vision - Answer b. decreased respiratory rate d. decreased LOC
e. double vision
Along with absent deep tendon reflexes, oliguria.
A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching? a. we will monitor your blood pressure every 2 hours b. your fluid intake will be limited to no more than 125 milliliters per hour. c. You may have the feeling that you will begin breathing much faster than normal d. We will monitor your baby's heartbeat once every hour-Answer b. your intake of fluids will be limited to no more than 125 milliliters per hour.
-take the client's BP every 15-30 mins -hypotension is an adverse effect -causes respiratory depression. RR every 15 min
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first? a. A client who is at 37 weeks of gestation and reports a persistent headache b. A client who is at 38 weeks of gestation and reports irregular uterine contractions c. A client who is at 12 weeks of gestation and reports abdominal cramping d. A client who is at 26 weeks of gestation and describes intermittent numbness of the fingers - Answer a. a client who is at 37 weeks of gestation and describes a constant headache
Constant headache is a symptom of preeclampsia
- uterine contractions can be in the latent stage of labor
- abdominal cramping can be having a miscarriage tingling of the fingers may be experiencing brachial plexus traction syndrome from drooping of the shoulders
c. If I need to leave my room, I will ask that the nurse take my baby back to the nursery d. I can remove my baby's security band when I bathe her-Answer c. I will call the nurse to take my baby back to the nursery whenever I must leave my room
Never leave the baby alone but if the parent must leave the room, then the parent can call the nurse to take the newborn back to the nursery. -always wear identification
- transported in a bassinet when moved from one location to another
A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. which of the following findings should the nurse report to the provider? a. calcium 9.2 mg/dL b. Heart rate 160/min c. blood glucose 28 mg/dL d. axillary temperature 36.5 C - Answer c. blood glucose 28 mg/dL
normal 40-45 mg/dL
- calcium 7.6 - 10. -fetal HR 110-160/ min, 80-100/min asleep, 180 when crying
- axillary 36.5 - 37.5 F
A nurse is collecting data on a client who is 32 hr postpartum. Which of the following findings should the nurse expect to find? a. Saturation of one perineal pad every 15 min b. Fundus 2 cm above the umbilicus c. Temperature of 39 C d. Urine output of 3,000 mL in 24 hr - Answer d. urine output of 3,000 mL in 24 hr
Should expect postpartum diuresis to begin approximately 12 hr after birth.
- fundus should be 1 to 2 cm below the umbilicus; should ascend 1 cm per day after birth.
- should not expect saturation of one perineal pad every 15 mins
A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse notify the provider about? a. BUN 14 mg/dL b. platelet count 200,000/mm c. Hematocrit 30% d. creatinine 1.0 mg/dL - Answer c. Hematocrit 30%
normal above 33%
- BUN: 10-20 mg/dL
- platelet: 150,000-400,000/mm
- creatinine: 0.5 - 1.0 mg/dL
A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and who has a positive hepatitis B test result. Which of the following should the nurse do? a. Instruct the client to avoid crowds until a repeat hepatitis B test is negative. b. Tell the client that they will have to initiate the hepatitis B vaccine series after birth. c. Instruct the client that hepatitis B immune globulin will be administered immediately. d. Inform the client that hepatitis B cannot be passed to the fetus - Response c. instruct the client that hepatitis B immune globulin will be administered immediately
- hepatitis B can cross the placenta and cause an infection in the fetus
- should receive the hepatitis B vaccine series within 14 days of the last known exposure to the virus or after a positive test result. immunization is safe in pregnancy. Nurse A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? a. Start giving about 240 mL (8 oz) with each feeding after the first week.
Will prevent heat loss.
- running water means temperature can change, dangerous for newborn.
A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome? a. negative rubella titer b. reactive non stress test c. 1-hr glucose tolerance screening test result of 150 mg/dL d. Hemoglobin 9.5 g/dL - Answer b. reactive non stress test
Indicates fetal well-being and is desirable outcome.
A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first? a. check the newborn's blood glucose level b. place the newborn under a radiant warmer c. Administer nonnutritive sucking d. swaddle the newborn - Answer a. Check the newborn's blood glucose level
First priority is to gather information from the client.
A nurse is caring for a client who is experiencing a postpartum hemorrhage. The nurse anticipates that the provider will order the following medication: a. indomethacin b. terbutaline c. methylergonovine d. betamethasone - Answer c. methylergonovine
Used to treat postpartum hemorrhage. An oxytoxic medication that stimulates the smooth muscle of the uterus to contract and, therefore, assist in reducing the loch. Should not be given to any client who has preeclampsia or hypertension.
- Indomethacin is an NSAID that relaxes smooth muscle of the uterus by inhibiting the production of prostaglandins. Indomethacin is used in the treatment of preterm labor. Terbutaline: Tocolytic medication administered to treat preterm labor by relaxing the smooth muscle of the uterus Betamethasone: Glucocorticoid medication administered to promote fetal lung maturity in those clients who are in preterm labor.
The nurse is going to administer clindamycin 450 mg PO to a client with endometritis. On hand the nurse has clindamycin 150 mg/capsule. How many capsules would the nurse administer? -Answer 3
A nurse is caring for a client who is at 20 wks of gestation and is in the clinic for a routine prenatal visit. Which of the following findings in the data from the client's medical record should the nurse notify the provider about? a. weight b. fundal height c. fetal heart rate d. blood pressure - Answer b. fundal height Measure of fundal height should be approximately the same as week of gestation; plus or minus 2 cm
A nurse employed on a postpartum unit is caring for a client with a hypotonic uterus who is bleeding vaginally excessively. Which of the following actions does the nurse perform first? a. Provide fundal massage to the client b. Initiate an indwelling urinary catheter for the client c. Administer methylergonovine IM to the client d. Administer oxygen via nonrebreather face mask to the client - Answer a. provide fundal massage for the client
This is to enhance the tone of the uterine muscles and also to express clots from the uterus and thus decrease bleeding.
healthcare provider? a. leukorrhea b. hyperpigmentation of the face c. varicose veins d. Braxton Hicks contractions occurring frequently - Answer d. Braxton Hicks contractions occurring frequently
These contractions serve to dilate the cervix prematurely, thus exposing the client to preterm labor.
- hyperpigmentation also referred to as "mask of pregnancy": benign
