Capstone Maternal Newborn Assessment Answer Key

Maternal Newborn Assessment 1. A nurse is reviewing the laboratory results for a client who is at 29 weeks.… the provider? WBC count 11,000/mm³ Hgb 11,2 g/dL Hct 34% Platelets 140,000/mm³ 2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take? Restrict protein intake to less than 40 g/day. Initiate seizure precautions for the client. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr. Encourage the client to ambulate twice per day. 3. A nurse is caring for a client who is in the transition phase of labor. Which of the following… Assist the client to void every 3 hr. Monitor contractions every 30 min. Place the client into a lithotomy position. Encourage the client to use a pant-blow breathing pattern. 4. A nurse is teaching the parents of a newborn how to care for their child’s uncircumcised penis. Which of the following instructions should the nurse include? Retract the foreskin until you feel resistance. Use a cotton swab to clean under the foreskin. Apply petroleum jelly to the foreskin. Wash the penis once per day with soup and water. 5. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings show potential prenatal complication? Periodic tingling of fingers Absence of clonus Leg cramps Blurred vision 6. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take? Administer oxytocin to the client via intravenous infusion. Apply oxygen at 2 L/min via nasal cannula. Prepare for insertion of an intrauterine pressure catheter. Assist the client into the knee-chest position. 7. A nurse is providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching? A peanut butter sandwich on wheat bread. A sliced apple and red grapes. A chocolate chip cookie with a glass of skim milk. A scrambled egg with cheddar cheese. 8. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following….. A client who gave a birth 1 day ago and needs Rh˳(D) immune globulin. A client who gave a birth 3 days ago and reports breath fullness. A client who gave a birth 12 hr. ago and reports and increase in urinary output. A client who gave a birth 8 hr. ago and is saturating a perineal pad every hour. 9. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome? Hyporeactivity Excessive high-pitched cry Acrocyanosis Respiratory rate of 50/min 10. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations…Which of the following actions should the nurse take first? Prepare the equipment necessary to initiate an amnioinfusion. Administer oxygen at 10 L/min via nonrebreather face mask. Discontinue the infusion of oxytocin. Place the client in a left lateral position. 11. A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take? Initiate continuous monitoring of the FHR. Administer a dose of betamethasone. Check the cervix for dilation every 8 hr. Request that the provider prescribe misoprostol PRN. 12. A nurse is reviewing a laboratory results for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? BUN 35 mg/dL Hgb 15 mg/dL Bilirubin 0.6 mg/dL Hct 37% 13. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance … that crosses the suture line. The nurse should identify the swellings as which of the following….? Nevus flammeus Caput succedaneum Cephalohematoma Erythema toxicum 14. A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect? Hypotonicity Moderate tremors of the extremities Axillary temperature 36.1°C (96.9° F) Excessive sleeping 15. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion? Contraction frequency every 3 min Contraction duration of 100 seconds Fetal heart rate with moderate variability Fetal heart rate of 118/min 16. A nurse is providing teaching to a group of women about risk factors for ovarian cancer. Which of the following should the nurse include? (Select all that apply.) Nulliparity History of breastfeeding (???) Previous use of oral contraceptives History of breast cancer Hormone replacement therapy 17. A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal…. Which of the following actions should the nurse take first? Change the client’s position. Palpate the uterus to assess for tachysystole. Increase the client’s IV infusion rate. Administer oxygen at 10 L/min via nonrebreather mask. 18. A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical … effect of epidural anesthesia? Polyuria Hypertensi on Pruritus Dry mouth 19. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer? Ampicillin Azithromyc in Ceftriaxone Acyclovir