RN Maternal Newborn Online Practice 2023 A

A nurse is caring for a newborn.

8 hr of age:

Temp: 37.1 C(98.8 F) Axillary

Pulse rate: 132/min

Resp rate: 52/min

36 hr of age:

Temp: 36.1 C (97 F) Axillary

Pulse rate: 160/min

Resp rate: 78/min

For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one disease process.

Poor feeding: Hypoglycemia, Hyperbilirubinemia, Sepsis

Lethargy: Hypoglycemia, Sepsis

Yellow sclera and oral mucosa: Hyperbilirubinemia, Sepsis

Decreased temperature: Hypoglycemia, Sepsis

Respiratory distress: Hypoglycemia, Sepsis

Ecchymotic caput succedaneum: Hyperbilirubinemia

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

a. decreased heart rate

b. chin quivering

c. pinpoint pupils

d. slowed respirations

b. Chin quivering

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

a. "I should increase my protein intake to 60 g each day."

b. "I should drink 2 liters of water each day"

c. "I should increase my overall daily caloric intake by 300 calories each day."

d. "I should take 600 micrograms of folic acid each day."

d. "I should take 600 micrograms of folic acid each day."

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

a. Maintain the client NPO throughout the procedure.

b. Place the client in a supine position.

c. Instruct the client to massage the abdomen to stimulate fetal movement.

d. Instruct the client to press the provided button each time fetal movement is detected.

d. Instruct the client to press the provided button each time fetal movement is detected

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?

a. Ensure the parent's identification band number matches the newborn's identification band number

b. Ask the parent's to verify their name and date of birth.

c. Check the newborn's security tag number to ensure it matches the newborn's medical record

d. Match the newborn's date and time of birth to the information in the parent's medical record.

a. Ensure the parent's identification band number matches the newborn's identification band number

A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

a. Late decelerations

b. Moderate variability of the FHR

c. Cessation of uterine dilation

d. Prolonged active phase of labor

a. Late decelerations

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

a. Oligohydramnios

b. Hyperemesis gravidarum

c. Leukorrhea

d. Periodic tingling of fingers

a. Oligohydramnios

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

a. Percutaneous umbilical blood sampling

b. Amnioinfusion

c. Biophysical profile (BPP)

d. Chorionic villus sampling (CVS)

c. Biophysical profile (BPP)

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

a. Acrocyanosis

b. Transient strabismus

c. Jaundice

d. Caput succedaneum

c. Jaundice

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply)

a. Cholecystitis

b. Hypertension

c. Human papillomavirus

d. Migraine headaches

e. Anxiety disorder

a. Cholecystitis, b. Hypertension, c. Migraines headaches

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?

a. "The test should take 10 to 15 minutes to complete."

b. "You will lay in a supine position throughout the test."

c. "You should not eat or drink for 2 hours before the test."

d. "You should press the handheld button when you feel your baby move."

d. "You should press the handheld button when you feel your baby move."

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statement by the client indicates an understanding of the teaching?

a. "I will eat foods that taste good instead of balancing my meals."

b. "I will avoid having a snack before I go to bed each night."

c. "I will have a hot cup of tea with each meal."

d. "I will eliminate products that contain dairy from my diet."

a. "I will eat foods that taste food instead of balancing my meals."

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report the provider?

a. Substernal retractions

b. Acrocyanosis

c. Overlapping suture lines

d. Head circumference

a. Substernal retractions

A nurse is teaching a client who us at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

a. Shortness of breath when climbing stairs

b. Swelling of feet and ankles at the end of the day

c. Headache that is unrelieved by analgesia

d. Braxton hicks contractions

c. Headache that is unrelieved by analgesia

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority?

a. Perform nitrazine testing

b. Assess the fluid

c. Check cervical dilation

d. Begin FHR monitoring

d. Begin FHR monitoring

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should should the nurse expect?

a. Decreased platelet count

b. Increased erythrocyte sedimentation rate (ESR)

c. Decreased megakaryocytes

d. Increased WBC

a. Decreased platelet count

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

a. Determine respiratory function

b. Increase the IV fluid rate

c. Access emergency medications from cart

d. Collect a maternal blood sample for a coagulopathy studies

a. Determine respiratory function

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?

a. A newborn who is 26 hr old and has erythema toxicum on their face

b. A newborn who is 32 hr old and has not passed a meconium stool

c. A newborn who is 12 hr old and has pink-tinged urine

d. A newborn who is 18 hr old and has an axillary temp of 37.3 C (99.9 F)

d. A newborn who is 18 hr old and has an axillary temp of 37.3 C (99.9 F)

A nurse is caring for client who is at 22 weeks of gestation and HIV positive. Which of the following actions should the nurse take?

a. Administer penicillin G 2.4 million units IM to the client

b. Instruct the client to schedule an annual pelvic examination

c. Tell the client they will start medication for HIV examination

d. Report the client's condition to the local health department

d. Report the client's condition to the local health department

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

a. "The nurse will carry your baby their arms to the nursery for scheduled procedures."

b. "We will document the relationship of visitors in your medical record."

c. "It's okay for your baby to sleep in the bed with you while in the hospital."

d. "Staff members who take care of your baby will be wearing a photo identification badge."

d. Staff members who take care of your baby will be wearing a photo identification badge

A nurse is assessing a newborn who was born at 26 weeks gestation using the New Ballard Score. Which of the following findings should the nurse expect?

a. Minimal arm recoil

b. Popliteal angle of 90 degrees

c. Creases over the entire foot sole

d. Raised areolas with 3 to 4 mm buds

a. Minimal arm recoil

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?

a. Hypertonia

b. Increased feeding

c. Hyperthermia

d. Respiratory distress

d. Respiratory distress

A nurse in a clinic is caring for a 16 year old adolescent.

Which of the following findings should the nurse report to the provider? Select all that apply.

a. Abdominal assessment

b. Vaginal discharge

c. Heart rate

d. Temperature

e. Dyspareunia

f. Condom usage

a. Abdominal assessment

b. Vaginal discharge

d. Temperature

e. Dyspareunia

f. Condom usage

A nurse in a clinic is caring for a 16 year old adolescent.

Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings?

For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.

a. Abdominal pain

b. Greenish discharge

c. Diabetes

d. Pain on urination

e. Absence of condom use

Abdominal pain: Gonorrhea

Greenish discharge: Trichomoniasis, Gonorrhea

Diabetes: Candidiasis

Pain on urination: Trichomoniasis, Gonorrhea, Candidiasis

Absence of condom use: Trichomoniasis, Gonorrhea, Candidiasis

The nurse is reviewing laboratory results in the adolescent's medical record. Which of the conditions is the client most likely developing?

Complete the following sentence by using the list of options.

The adolescents is most likely developing 1.__________________ as evidenced by 2. ________________.

1. Pelvic inflammatory disease, ectopic pregnancy, pyelonephritis

2. C-reactive protein, urinalysis

The adolescent is most likely developing 1. Pelvic inflammatory disease, as evidenced by 2. C-reactive protein.

The nurse is reviewing laboratory results in the adolescent's medical record.

The nurse suspects the adolescent is experiencing pelvic inflammatory disease. and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe?

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should anticipate a provider's prescription for 1._____________ and 2.______________.

The nurse should anticipate a provider's prescription for 1. ceftriaxone and 2. doxycycline.

A nurse is reviewing the provider's prescription in the adolescent's medical chart. Complete the following sentence by using the list of options.

The nurse should first implement 1. _____________ and 2. ____________________.

The nurse should first implement 1. providing education on medications and 2. Administering ceftriaxone.

A nurse is reviewing the provider's prescription in the adolescent's medical chart.

The nurse has just reviewed discharge instructions with the adolescent. Which of the following indicates whether the adolescent understands the teaching or requires further education?

For each of the statements made by the adolescent, click to specify whether the statement indicates an understanding or requires further education.

1. "I should continue taking all my medications even if I don't show any symptoms."

2. "If I continue to get this type of infection, it can affect my ability to have kids in the future."

3. "I should go to the emergency department if my urine turns dark."

4. "As long as I keep my IUD, I don't need to use condoms."

5. "I'm more likely to get a sunburn while taking these medications."

1, 2, 5: Indicates understanding

3, 4: Requires further education

A nurse teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates and understanding of the teaching?

a. "I will need to increase my insulin doses during the first trimester."

b. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater."

c. "I will continue taking my insulin if I experience nausea and vomiting."

d. "I will ensure that my bedtime snack is high in refined sugar."

c. "I will continue taking my insulin if I experience nausea and vomiting."

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

a. Large for gestational age

b. Hyperglycemia

c. Bradypnea

d. Vomiting

d. Vomiting

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

a. Restrict hourly intake to 150 ml/hr

b. Have calcium gluconate readily available

c. Assess deep tendon reflexes every 6 hr

d. Monitor intake and output every 4 hr

b. Have calcium gluconate readily available

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication>

a. Increased fetal movement

b. Leakage of fluid from the vagina

c. Upper abdominal discomfort

d. Urinary frequency

b. Leakage of fluid from the vagina

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?

a. Depression

b. Polyuria

c. Hypotension

d. Urticaria

a. Depression

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

a. O2 saturation

b. Temperature

c. Blood pressure

d. Urinary output

b. Temperature

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. Place the steps in order.

Identify the attitude of the head, palpate for fetal part presenting at the inlet, palpate the fundus to identify fetal part, determine the location of the fetal back.

1. Palpate the fundus to identify the fetal part

2. Determine the location of the fetal back

3. Palpate for the fetal part presenting at the inlet

4. Identify the attitude of the head

A nurse caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

a. Determine progression of dilation and effacement

b. Perform Leopold's maneuvers

c. Complete a sterile speculum exam

d. Evaluate cervix

b. Perform Leopold's maneuver

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

a. Reassess the client in 2 hr

b. Administer simethicone

c. Assess the client to empty their bladder

d. Instruct the client to lie on their right side

c. Assist the client to empty their bladder

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

a. "You should take the medication within 72 hrs of unprotected sex."

b. "You should avoid taking this medication if you are on oral contraception."

c. "If you don't start your period within 5 days of taking this medication you will need a pregnancy test."

d. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

a. "You should take the medication within 72 hrs following unprotected sex."

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?

a. Feed the newborn 1 oz of water every 4 hr

b. Apply lotion to the newborn's skin three times a day

c. Remove all clothing from the newborn except the diaper

d. Discontinue therapy if the newborn develops a rash

c. Remove all clothing from the newborn except the diaper

A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

a. Passive descent

b. Active

c. Early

d. Descent

b. Active

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?

a. Administer aspirin for pain

b. Elevate the affected leg

c. Massage the affected leg every 12 hr

d. Apply cold compresses to the affected calf

b. Elevate the affected leg

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?

a. A client who is at 11 weeks gestation and reports abdominal cramping

b. A client who is at 15 weeks gestation and reports tingling and numbness in right hand

c. A client who is at 20 weeks of gestation and reports constipation for the past 4 days

a. A client who is at 11 weeks gestation and reports abdominal cramping

A nurse is preparing to administer azithromycin to a client who is at 16 weeks gestation and has a positive chlamydia culture. The prescription states, 'Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round to nearest whole number)

4 tablets

A nurse is observing a new guardian for their crying newborn who is bottle feeding. Which of the following actions by the guardians should the nurse recognize at positive parenting behavior?

a. Lays the newborn across their lap and gently sways

b. Places the newborn in the crib in the prone position

c. Offers the newborn a pacifier dipped in formula

a. Lays the newborn across their lap and gently sways

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

a. Place the client in a supine position for 30 min following the first dose of anesthetic solution

b. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution

c. Monitor client's blood pressure every 5 min following the first dose of anesthetic solution

d. Ensure the client has been NPO 4 hr prior to the placement of epidural

c. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply)

a. Flaccid uterus

b. Cervical laceration

c. Excess vaginal bleeding

d. Increased afterbirth cramping

e. Increased maternal temperature

a. Flaccid uterus, c. Excess vaginal bleeding

A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse expect to report to the provider?

a. Frequent vomiting with weight loss of 3 lb in 1 week

b. Reports of mood swings

c. Nosebleeds occurring approximately 3 times per week

d. Increased vaginal discharge

a. Frequent vomiting with weight loss of 3 lb in 1 week

A nurse is performing a routine assessment on a client who is at 18 weeks gestation. Which of the following findings should the nurse expect?

a. Deep tendon reflexes 4+

b. Fundal height 14 cm

c. Blood pressure 142/94 mmHg

d. FHR 152/min

d. FHR 152/min

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

a. Blood pressure 105/64 mmHg

b. Heart rate 98/min

c. Urine output of 280 ml within 8 hr

d. Urine negative for ketones

a. Blood pressure 105/64 mmHg

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

a. Continue the newborn's Apgar score

b. Verify the newborn's identification

c. Administer vitamin K to newborn

b. Verify the newborn's identification

A nurse is assessing a client who is at 30 weeks gestation during a routine prenatal visit. Which of the followings should the nurse report to the provider?

a. Swelling of the face

b. Varicose veins in the calves

c. Nonpitting 1+ ankle edema

a. Swelling of the face

A nurse on an antepartum unit is caring for a client

Which of the following nursing actions should the nurse plan to take?

For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the client.

Weigh perineal pads

Assess cervical dilation

Administer methotrexate

Insert a large bore IV catheter

Indicated: Weigh perineal pads, insert large bore IV catheter

Contraindicated: Assess cervical dilation, administer methotrexate

A nurse is caring for a newborn. Which of the following actions should the nurse plan to implement?

For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.

1. Educate the parents to begin range of motion exercises on the affected arm after 1 week

2. Assess for grasp reflex in the affected extremity

3. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt

4. Instruct the parent to limit physical handling for 2 weeks

Educate the parents to begin range of motion exercises on the affected arm after 1 week: Indicated

Assess for grasp reflex in the affected extremity: Indicated

Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt: Indicated

Instruct parents to limit physical handling for 2 weeks: Contraindicated

A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the following findings should the nurse report to the provider? Select 3 findings that should be reported.

a. Uterine contractions

b. Fetal heart rate

c. Gestational age

d. Vaginal examination

e. Maternal blood pressure

a. Uterine contractions, c. Gestational age, d. Vaginal examination

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

a. A client who has gestational diabetes and a fasting blood glucose of 120 mg/dl (less than 95 mg/dl)

b. A client who is at 34 weeks gestation and reports epigastric pain

c. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dl (11 to 16 g/dl)

b. A client who is at 34 weeks of gestation and reports epigastric pain

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

a. Emotional liability

b. Focusing phase

c. Cognitive restructuring

a. Emotional liability

A nurse is caring for a newborn who is 48 hr old. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

2 Actions to take:

Potential condition:

2 Parameters to monitor:

2 Actions to take:

1. Place newborn skin to skin on birthing parent's chest

2. Encourage birthing parent to breastfeed

Potential condition: Cold stress

Parameters to monitor:

1. Temperature

2. Blood glucose level

A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? Select all that apply.

a. Respiratory findings

b. Temperature

c. Oxygen saturation

d. Central nervous system findings

e. Gastrointestinal findings

d. Central nervous system findings, e. gastrointestinal findings

A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

a. Check the client's temperature

b. Observe for uterine contractions

c. Administer Rh immune globulin

d. Monitor the FHR

d. Monitor the FHR

A nurse in the antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider?

a. 1 hr glucose tolerance test

b. Hematocrit

c. Fundal height measurement

c. Fundal height measurement