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Maternal Newborn CMS Exam With Q&A
A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical fndings should the nurse identify as an indication of postpartum infection? a. Unilateral breast pain b. Persistent abdominal striae c. Lochia alba d. WBC count 12,000/mm3 - ANSWER>>a. Unilateral breast pain A nurse is assessing client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood glucose 110 mg/dL b. Deep tendon reRexes of 2+ c. Urine protein of 3+ d. Hemoglobin 13 g/dL - ANSWER>>c. Urine protein of 3+ 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. "This medication improves tissue perfusion." b. "This medication increases cardiac output." c. "This medication stabilizes the fetal heart rate." d. "This medication prevents seizures." - ANSWER>>d. "This medication prevents seizures." A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? a. "You will have dilation and effacement of the cervix." b. "Your contractions will become temporarily regular." c. "You will have bloody show." d. "Your contractions will become more intense when walking." - ANSWER>>b. "Your contractions will become temporarily regular."
A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy? a. Check the newborn's identification using the crib card. b. Replace the infant's identification band after his name has been recorded. c. Require visitors to wear an identification band. d. Obtain an imprint of the infant's feet prior to taking him to the nursery. - ANSWER>>d. Obtain an imprint of the infant's feet prior to taking him to the nursery. 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 massage. Which of the following actions should the nurse take? a. Apply an ice pack to the incision site. b. Replace the surgical dressing. c. Administer 500 mL lactated Ringer's IV bolus. d. Evaluate urinary output. - ANSWER>>d. Evaluate urinary output.
. A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching? a. Wear nipple shields during the feeding. b. Use a breast binder for 2 days. c. Use plastic-lined breast pads. d. Apply cabbage leaves a^er feedings - ANSWER>>d. Apply cabbage leaves a^er feedings A nurse is calculating estimated date of birth using Naegele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated delivery in the next year? a. March 14 b. March 21 c. March 28 d. April 4 - ANSWER>>c. March 28
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? a. Lay the tape measure horizontally over the middle of the client's abdomen. b. Place the client in a left-lateral position to obtain the measurement. c. Ensure that the client has a full bladder before taking the measurement. d. Measure from the upper border of the pubis to the upper border of the fundus. - ANSWER>>d. Measure from the upper border of the pubis to the upper border of the fundus. A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help retrieve this common discomfort of pregnancy? a. Include 18 g of fiber in the diet each day. b. Drink 2 to 3 L of water each day.. c. Add 30 mL of mineral oil to each meal. d. Tale 60 mL of magnesium hydroxide once daily. - ANSWER>>b. Drink 2 to 3 L of water each day A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heart beat. Which of the following terms should the nurse use to document this finding? a. Goodell's sign b. Funic souffle c. Quickening d. Hegar's sign - ANSWER>>b. Funic souffle
. A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask b. Place newborn bassinets at least 3 feet apart. c. Place the newborn's foot on a sterile field during a heel stick.
d. Maintain airborne precautions in the nursery. - ANSWER>>b. Place newborn bassinets at least 3 feet apart. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent deep-tendon reflexes. Which of the following medications should the nurse administer? a. Phytonadione b. Acetylcysteine c. Protamine sulfate d. Calcium gluconate - ANSWER>>d. Calcium gluconate A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? a. Apply supra pubic pressure. b. Administer a diuretic to the client. c. Insert an indwelling urinary catheter. d. Encourage the client to void in the shower. - ANSWER>>d. Encourage the client to void in the shower. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. "Mothers will receive prophylactic treatment with acyclovir prior to delivery." b. "Transmission can occur via the saliva and urine of the newborn." c. "This infection requires airborne precautions are initiated for the newborn." d. "Lesions are visible on the mother's genitalia." - ANSWER>>b. "Transmission can occur via the saliva and urine of the newborn." A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory testused to evaluate this condition?
d. "I will insert a urinary catheter before I administer the medication." - ANSWER>>a. "You will lie on your side for 40 minutes after I administer the medication." A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? a. The client will identify individual family member roles. b. The client will have adequate nutritional intake. c. The client will verbalize appropriate car seat safety. d. The client will demonstrate proper bathing of the infant. - ANSWER>>b. The client will have adequate nutritional intake.
. A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? a. "Limit your fluid intake to four 8-ounce glasses per day." b. "Count your baby's movements daily." c. "Reduce your calcium intake to less than 1 gram per day." d. "Alternate arms each time you check your blood pressure." - ANSWER>>b. "Count your baby's movements daily." A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS). The client ismultigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? a. "We need to know if you are positive for GBS at the time of delivery." b. "There was no indication of GBS in your earlier prenatal testing." c. "You didn't report any symptoms of GBS during your pregnancy." d. "Your previous deliveries were all negative for GBS." - ANSWER>>a. "We need to know if you are positive for GBS at the time of delivery."
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? a. Single palmar creases b. Transient circumoral cyanosis c. Rust-stained urine d. Subconjunctival hemorrhage - ANSWER>>b. Transient circumoral cyanosis A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Respiratory rate 18/min b. Cool, clammy skin c. Urinary output 30 mL/hr d. Bounding pulses - ANSWER>>b. Cool, clammy skin A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? a. "You can take 400 milligrams of ibuprofen for discomfort." b. "You should take 600 micrograms of folic acid per day." c. "You can take black cohosh once a day for insomnia." d. "You should limit your daily fluid intake to 1,000 milliliters per day." - ANSWER>>b. "You should take 600 micrograms of folic acid per day." A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? a. Increase the infusion rate every 30 to 60 min. b. Maintain the client in a supine position. c. Limit IV intake to 4 L per 24 hr. d. Titrate the infusion rate by 4 milliunits/min. - ANSWER>>a. Increase the infusion rate every 30 to 60 min.
. A nurse is planning to teach a group of clients who are pregnant about breast feeding after returning to work. Which of the following information should the nurse include in the teaching? a. "Thawed breast milk that is unused can be refrozen." b. "Breast milk can be stored at room temperature for up to 12 hours." c. "Breast milk can be stored in a deep freezer for 12 months." d. "Thawed breast milk can be refrigerated for up to 72 hours." - ANSWER>>c. "Breast milk can be stored in a deep freezer for 12 months." A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. Erythema toxicum b. Periauricular papillomas c. Telangiectatic nevi d. Facial petechiae - ANSWER>>d. Facial petechiae A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? a. Length from head to heel of 40 cm (15.7 in) b. Bulging fontanels c. Chest circumference 2 cm (0.8) smaller than the head circumference d. Nasal Raring - ANSWER>>c. Chest circumference 2 cm (0.8) smaller than the head A nurse is assisting with a precipitous delivery of a term newborn. After the head emerges, the nurse palpates the cord around the newborn's neck. Which of the following actions should the nurse take? a. Apply fundal pressure. b. Place the client in the knee-chest position. c. Apply a water-based lubricant to the cord. d. Slip the cord over the newborn's head. - ANSWER>>d. Slip the cord over the newborn's head.
A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care? a. Wash the circumcision site with mild soap and water 24 hr following the procedure. b. Take off the plastic bell 2 hr after the procedure. c. Monitor for bleeding every 15 min for the first hour. d. Remove the yellow drainage on the second postoperative day. - ANSWER>>c. Monitor for bleeding every 15 min for the first hour.
. A nurse is providing discharge instructions to a client who is 24 hr postpartum and has decided not to breast feed. Which of the following instructions should the nurse include in the teaching? a. "Shower daily, allowing warm water to run directly over your breasts." b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule." c. "Wear a loose-5mng, nonbinding bra for 72 hours." d. "Pump your breasts twice daily to relieve discomfort from engorgement."
- ANSWER>>b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? a. Respiratory rate 14/min b. Blood pressure 142/92 mm Hg c. Urine output 100 mL in 3 hr d. Pulse 58/min 42 - ANSWER>>b. Blood pressure 142/92 mm Hg A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has molding with overlapping suture lines b. A female newborn who has blood-tinged vaginal discharge c. A newborn who has a high-pitched cry with exaggerated Moro reflex
placing the client in a side-lying position, which of the following actions should the nurse take? a. Decrease the rate of IV fluids. b. Elevate the client's head. c. Administer oxygen via a face mask. d. Perform fetal scalp stimulation. - ANSWER>>c. Administer oxygen via a face mask.
. A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? a. Keep the newborn in a side-lying position. . Restrict the newborn's fluid intake. c. Cover the newborn's bladder with a sterile, non-adherent dressing. d. Exert gentle pressure on the newborn's bladder with sterile gauze. - ANSWER>>c. Cover the newborn's bladder with a sterile, non-adherent dressing. A nurse is reviewing the laboratory report of a client who is 24 hr postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take? a. Initiate IV access for isotonic solution with an 18-gauge catheter. b. Prepare the client for a blood transfusion. c. Administer an iron supplement to the client. d. Instruct the client that the provider will check for placental fragments. - ANSWER>>c. Administer an iron supplement to the client. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider? a. Deep tendon reflex 2+ b. Absence of clonus c. Facial Rushing d. Urine output 20 mL/hr - ANSWER>>d. Urine output 20 mL/hr
. A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? a. Place an ice pack on the newborn's heel 5 min before the procedure. b. Cleanse the newborn's heel with an alcohol swab after the procedure. c. Use an automatic puncture device on the heel. d. Puncture the heel in the inner aspect of the foot. - ANSWER>>c. Use an automatic puncture device on the heel. A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first? a. Assist the client to the bathroom. b. Offer the client a sitz bath. c. Insert a urinary catheter. d. Pour warm water over the client's perineum. - ANSWER>>a. Assist the client to the bathroom. A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? a. Lentils b. Oatmeal c. Cabbage d. Asparagus - ANSWER>>b. Oatmeal A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Proteinuria b. Hyperemesis c. Hypoxia d. Hemorrhage - ANSWER>>d. Hemorrhage . A nurse is in a clinic caring for a client who is in her second trimester pregnancy. The client expresses concern about preparing her 2- year- old- child for a new sibling. Which of the following is an appropriate response by the nurse?
c. Fasting blood glucose 180 mg/dL d. Hematocrit 35% - ANSWER>>c. Fasting blood glucose 180 mg/dL A nurse is caring for a client who is at 35 weeks of gestation and is on bed rest due to preeclampsia. Which of the following is an important action for the nurse to take? a. Maintain NPO status b. Obtain BP every 8 hours c. Keep the lights dimmed in the room. d. Auscultate fetal heart tones twice per day - ANSWER>>c. Keep the lights dimmed in the room. A nurse is caring for a client who is 2 days postpartum and states "I want to continue breast feeding, but my nipples are sore." Which of the following responses should the nurse make? a. "Removing breast shields from your bra ll decreased discomfort." b. "You should switch your infant to formula until the soreness goes away." c. "Allow expressed milk to air dry on the nipples after feeding your infant." d. "Apply an antibiotic ointment to the nipples prior to each feeding." - ANSWER>>c. "Allow expressed milk to air dry on the nipples after feeding your infant." A nurse is caring for a newborn immediately following birth notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. a. Lace the bulb syringe in the newborn's mouth (2) b. Compress the bulb syringe (1) c. Assess the newborn for reflex bradycardia (4) d. Set the bulb syringe suction the newborn's nose (3) - ANSWER>>b. Compress the bulb syringe (1) a. Lace the bulb syringe in the newborn's mouth (2) d. Set the bulb syringe suction the newborn's nose (3) c. Assess the newborn for reflex bradycardia (4)
A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports abdominal pain during breast feeding b. A client who reports changing her perineal pad every 2 hours c. A client who has urine output of 250 mL in 6 hr d. A client who as hyporeflexia while receiving IV magnesium sulfate - ANSWER>>d. A client who as hyporeflexia while receiving IV magnesium sulfate A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? a. "Insert the diaphragm up to 12 hours before intercourse." b. "Remove the diaphragm 2 hours after intercourse." c. "Replace the diaphragm every 2 years." d. "Use 2 teaspoons baby oil to lubricate the diaphragm before insertion." - ANSWER>>c. "Replace the diaphragm every 2 years." A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Hyperemesis gravidarum b. Postpartum hemorrhage c. Incompetent cervix d. Ectopic pregnancy - ANSWER>>b. Postpartum hemorrhage A nurse is providing vehicle safety education to parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. "You should secure your newborn's car seat at a 60 degree angle." b. "Your newborn will need to have a car seat test prior to discharge." c. "Place your newborn in a front-facing car seat in the back seat of the vehicle."
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? a. Respiratory rate 11/min b. Urine output 130 mL /4 hr c. Deep tendon reflexes absent d. Fetal heart rate 120/min e. Flushing of face - ANSWER>>c. Deep tendon reflexes absent A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff nurses to report to the provider? A. Contraction durations of 95 to 100 seconds B. Fetal heart rate is 140/min C. Absent early deceleration of fetal heart rate D. Contraction frequency of 2 to 2 min apart - ANSWER>>A. Contraction durations of 95 to 100 seconds A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take? A. Measure the abdominal circumference at the level for the newborn's umbilicus ever 12 hr. B. Administer nitric oxide inhalation therapy to the newborn C. Provide the newborn with an iron-rich formula containing vitamin B every 2 hr D. Inset an orogastric decompression tube with low wall suction - ANSWER>>C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication could cause me to experience ringing in my ears." B. "This medication could cause me to experience frequent urination."
C. "This medication could cause me to experience blurred vision." D. "This medication could cause me to experience heart palpitations." - ANSWER>>D. "This medication could cause me to experience heart palpitations." A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following findings should the nurse expect? A. Minimal arm recoil B. Creases over the entire sole C. Popliteal angle of less than 90 degree D. Sparse lanugo - ANSWER>>D. Sparse lanugo A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection? A. Placenta previa B. Midline episiotomy C. Gestational hypertension D. Meconium-stained fluid - ANSWER>>B. Midline episiotomy A nurse in a provider's office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use the Nagele's rule to calculate the estimated date of delivery. (use the MMDD format with four numerals and no spaces or punctuation.) - ANSWER>> A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Keep the newborn supine throughout treatment B. Avoid using lotion or ointment on the newborn's skin C. Measure the newborn's temperature every 8 hr D. Dress the newborn in lightweight clothing - ANSWER>>B. Avoid using lotion or ointment on the newborn's skin
