Maternity Exam 3: Practice Questions

A nurse is teaching a client diagnosed with gestational diabetes about dietary management. Which statement by the client indicates a correct understanding of the dietary recommendations?

A) "I should avoid all carbohydrates to control my blood sugar levels."

B) "I can have a balanced diet that includes carbohydrates, but I need to monitor my portion sizes."

C) "I can eat as many fruits as I want since they are healthy."

D) "I should only eat proteins and fats to manage my blood sugar."

B) "I can have a balanced diet that includes carbohydrates, but I need to monitor my portion sizes."

A 28-year-old pregnant client is diagnosed with gestational diabetes at 24 weeks of gestation. Which of the following assessments is the nurse's priority?

A) Fetal heart rate monitoring

B) Blood glucose level monitoring

C) Maternal weight gain tracking

D) Blood pressure measurement

B) Blood glucose level monitoring

A nurse is planning care for a client with gestational diabetes. Which intervention should the nurse prioritize to promote the client's health?

A) Teaching the client about insulin administration.

B) Encouraging the client to participate in daily exercise.

C) Assessing the client's understanding of gestational diabetes.

D) Providing a referral to a dietitian for meal planning.

B) Encouraging the client to participate in daily exercise.

A client with gestational diabetes is prescribed insulin. Which nursing diagnosis is most appropriate for this client?

A) Risk for infection related to elevated blood glucose levels.

B) Ineffective health management related to knowledge deficit about diabetes.

C) Imbalanced nutrition: more than body requirements related to dietary choices.

D) Anxiety related to the diagnosis of gestational diabetes.

B) Ineffective health management related to knowledge deficit about diabetes.

A nurse reviews the lab results of a client with gestational diabetes. Which value indicates that the client's blood glucose levels are within the desired range?

A) Fasting glucose of 130 mg/dL

B) Two-hour postprandial glucose of 140 mg/dL

C) Fasting glucose of 90 mg/dL

D) Random glucose of 160 mg/dL

C) Fasting glucose of 90 mg/dL

During a follow-up visit, the nurse assesses a client with gestational diabetes. The client reports frequent headaches and fatigue. What should the nurse do next?

A) Suggest increasing carbohydrate intake.

B) Assess the client's blood glucose levels.

C) Educate the client about headache management.

D) Schedule an appointment for a nutritional counseling session.

B) Assess the client's blood glucose levels.

A nurse is educating a client with gestational diabetes about signs of hypoglycemia. Which of the following should be included in the teaching?

A) "You may experience increased thirst and frequent urination."

B) "Hypoglycemia can cause symptoms like shakiness and sweating."

C) "You should expect headaches as a common symptom."

D) "Hypoglycemia is often accompanied by high blood pressure."

B) "Hypoglycemia can cause symptoms like shakiness and sweating."

A nurse is reviewing the care plan for a client with gestational diabetes. Which goal would be the most appropriate for this client?

A) Maintain normal blood glucose levels throughout the pregnancy.

B) Achieve a 5% weight loss by the end of the pregnancy.

C) Limit physical activity to reduce stress on the fetus.

D) Increase intake of simple sugars to prevent hypoglycemia.

A) Maintain normal blood glucose levels throughout the pregnancy.

A client with gestational diabetes is worried about the long-term effects of the condition on her baby. What is the most appropriate response by the nurse?

A) "The baby will likely be very large, which may complicate delivery."

B) "Most babies born to mothers with gestational diabetes are healthy."

C) "Gestational diabetes will not affect your baby at all."

D) "There are no risks to your baby; you should not worry."

B) "Most babies born to mothers with gestational diabetes are healthy."

A nurse is preparing to discharge a client with gestational diabetes. Which discharge instruction is crucial for the nurse to provide?

A) "You will need to continue monitoring your blood sugar even after delivery."

B) "You can stop monitoring your blood sugar immediately after delivery."

C) "There is no need to follow up with your healthcare provider after discharge."

D) "You should increase your carbohydrate intake to normalize your blood sugar."

A) "You will need to continue monitoring your blood sugar even after delivery."

A nurse is caring for a client diagnosed with preeclampsia who is experiencing severe headaches and visual disturbances. Which nursing intervention is the priority?

A) Administer prescribed antihypertensive medication.

B) Prepare the client for a possible cesarean delivery.

C) Encourage the client to rest in a dark, quiet room.

D) Assess the client's urine output and protein levels.

A) Administer prescribed antihypertensive medication.

A client with preeclampsia is being monitored for potential complications. Which finding would indicate a progression toward eclampsia?

A) Increased fetal heart rate variability

B) Elevated blood pressure above 160/110 mmHg

C) Presence of epigastric pain

D) Decreased maternal weight gain

C) Presence of epigastric pain

During a prenatal visit, a client with a history of hypertension is found to have a blood pressure of 145/95 mmHg and +2 protein in the urine. Which action should the nurse take first?

A) Schedule the client for an ultrasound.

B) Instruct the client to monitor her blood pressure at home.

C) Notify the healthcare provider immediately.

D) Educate the client about dietary modifications.

B) Instruct the client to monitor her blood pressure at home.

A nurse is teaching a group of pregnant clients about the signs and symptoms of preeclampsia. Which statement by a client indicates a need for further teaching?

A) "I should report sudden swelling in my hands and face."

B) "Seeing spots or having blurry vision could be a sign of preeclampsia."

C) "I can ignore headaches unless they are severe."

D) "High blood pressure can be a warning sign of preeclampsia."

C) "I can ignore headaches unless they are severe."

A client diagnosed with preeclampsia is prescribed magnesium sulfate. What is the primary purpose of this medication in the management of preeclampsia?

A) To control hypertension

B) To prevent seizures

C) To promote fetal lung maturity

D) To decrease edema

B) To prevent seizures

A pregnant client diagnosed with HIV is concerned about the risk of transmitting the virus to her baby. Which of the following statements by the nurse is most appropriate?

A) "You can eliminate the risk of transmission by breastfeeding."

B) "The risk of transmission is highest during labor and delivery."

C) "Taking antiviral medication during pregnancy has no effect on transmission."

D) "You should avoid all contact with your baby after delivery."

B) "The risk of transmission is highest during labor and delivery."

A nurse is caring for a pregnant client who is HIV-positive and receiving antiretroviral therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the treatment?

A) Complete blood count (CBC)

B) CD4 cell count

C) Liver function tests (LFTs)

D) Urinalysis

B) CD4 cell count

During a prenatal visit, a nurse assesses a client who is HIV-positive. Which statement indicates that the client understands how to reduce the risk of transmission to her baby during delivery?

A) "I will have a vaginal delivery regardless of my viral load."

B) "I should consider a cesarean delivery if my viral load is high."

C) "I will delay delivery until I have a negative HIV test."

D) "Breastfeeding will reduce the risk of transmission."

B) "I should consider a cesarean delivery if my viral load is high."

A pregnant client with HIV is concerned about how her condition will affect her labor and delivery. Which of the following nursing interventions is most appropriate to include in her plan of care?

A) Provide education on the benefits of vaginal delivery.

B) Schedule regular prenatal visits to monitor fetal growth and development.

C) Discuss the possibility of immediate postpartum breastfeeding.

D) Emphasize the importance of avoiding all medications during labor.

B) Schedule regular prenatal visits to monitor fetal growth and development.

A nurse is discussing postpartum care with a client who is HIV-positive. Which statement should the nurse include to promote safe practices?

A) "You can breastfeed if your viral load is undetectable."

B) "There is no need for follow-up appointments after delivery."

C) "You should avoid all contact with your newborn until your HIV is cured."

D) "You can start using hormonal contraception immediately after delivery."

A) "You can breastfeed if your viral load is undetectable."

A nurse is caring for a client diagnosed with hydramnios. Which assessment finding should the nurse monitor closely due to the increased risk associated with this condition?

A) Maternal weight gain

B) Fetal heart rate variability

C) Fundal height measurements

D) Maternal blood pressure

C) Fundal height measurements

A pregnant client presents with hydramnios at 34 weeks of gestation. The healthcare provider is considering a possible amniocentesis. What is the primary purpose of this procedure in this situation?

A) To assess fetal lung maturity

B) To relieve pressure on the uterus

C) To obtain amniotic fluid for analysis

D) To induce labor if necessary

C) To obtain amniotic fluid for analysis

A nurse is educating a client with hydramnios about potential complications. Which statement by the client indicates a need for further teaching?

A) "I might be at risk for preterm labor."

B) "Hydramnios can lead to fetal malformations."

C) "I should be aware of the risk for cord prolapse."

D) "There is no need for extra monitoring during my pregnancy."

D) "There is no need for extra monitoring during my pregnancy."

During a prenatal visit, a client is diagnosed with mild hydramnios. What is the most appropriate nursing intervention for this client?

A) Encourage bed rest throughout the pregnancy.

B) Schedule more frequent prenatal appointments.

C) Provide information about the need for immediate delivery.

D) Educate the client about reducing fluid intake.

B) Schedule more frequent prenatal appointments.

A client who is trying to conceive reports light spotting 7 days after ovulation. She is concerned this could be an early sign of miscarriage. What should the nurse advise the client?

A. "This spotting could be a sign of implantation bleeding, which is common and not a cause for concern."

B. "You should avoid physical activity until the spotting stops completely."

C. "Spotting is always a sign of miscarriage, so it's important to contact your healthcare provider immediately."

D. "Implantation bleeding is a sign that fertilization was unsuccessful, and you should prepare for your next cycle."

A. "This spotting could be a sign of implantation bleeding, which is common and not a cause for concern."

Rationale: Light spotting 6-12 days after ovulation can be a sign of implantation bleeding, which is a normal part of early pregnancy. It is not necessarily a sign of miscarriage.

A client calls the clinic stating she experienced mild cramping and light pink spotting a few days after a positive ovulation test. What is the best nursing response?

A. "The symptoms you are describing are consistent with a potential ectopic pregnancy."

B. "These symptoms may indicate implantation bleeding, which is a normal early sign of pregnancy."

C. "Cramping and spotting are signs that your menstrual cycle is about to begin."

D. "You should perform a home pregnancy test now to determine if you're pregnant."

B. "These symptoms may indicate implantation bleeding, which is a normal early sign of pregnancy."

Rationale: Mild cramping and light spotting a few days after ovulation can be indicative of implantation bleeding, which is common and normal in early pregnancy.

A client reports vaginal spotting 10 days after unprotected intercourse and is concerned she may have experienced implantation bleeding. Which characteristic would most support this as a likely cause of the spotting?

A. Heavy bleeding lasting 4-5 days

B. Bright red blood with clots

C. Light pink or brownish spotting for 1-2 days

D. Sharp abdominal pain accompanied by dizziness

C. Light pink or brownish spotting for 1-2 days

Rationale: Implantation bleeding is usually light in volume, often pink or brown in color, and lasts for only 1-2 days. Heavy bleeding or clots are more likely associated with menstruation or other conditions.

A nurse is educating a couple trying to conceive about the early signs of pregnancy. Which statement by the couple indicates a correct understanding of implantation bleeding?

A. "If I have implantation bleeding, it will be just like my regular period but shorter."

B. "Implantation bleeding can occur around the time my period is due, but it's usually lighter and shorter."

C. "Implantation bleeding means that I need to take a pregnancy test immediately."

D. "If I experience any type of bleeding, I should be concerned about a miscarriage."

B. "Implantation bleeding can occur around the time my period is due, but it's usually lighter and shorter."

Rationale: Implantation bleeding may occur close to the expected period but is typically lighter and shorter than a menstrual period. It does not require immediate pregnancy testing.

5. A client presents with light vaginal spotting and mild cramping two weeks after unprotected intercourse. Which nursing action is most appropriate in this situation?

A. Educate the client about the possibility of implantation bleeding and advise monitoring the spotting.

B. Recommend an emergency ultrasound to rule out complications such as ectopic pregnancy.

C. Administer hormonal therapy to prevent further bleeding and cramping.

D. Advise the client to avoid pregnancy testing for at least another week.

A. Educate the client about the possibility of implantation bleeding and advise monitoring the spotting.

Rationale: Light spotting and mild cramping could indicate implantation bleeding, which is normal. The nurse should educate the client on this possibility and advise monitoring without unnecessary interventions.

A client presents to the emergency department with sharp lower abdominal pain and vaginal spotting. The nurse notes a positive pregnancy test and a history of pelvic inflammatory disease (PID). Which action should the nurse prioritize?

A. Schedule the client for an ultrasound to confirm intrauterine pregnancy.

B. Administer IV fluids to manage dehydration from blood loss.

C. Inform the client that PID may cause spotting and prescribe antibiotics.

D. Assess for signs of shock and prepare for potential surgical intervention.

D. Assess for signs of shock and prepare for potential surgical intervention.

Rationale: Sharp abdominal pain and spotting in a pregnant woman with a history of PID are concerning for ectopic pregnancy, which can be life-threatening. The priority is to assess for signs of rupture and shock and prepare for surgical intervention if necessary.

A client at 6 weeks gestation presents with light vaginal bleeding and unilateral lower abdominal pain. Which diagnostic test should the nurse anticipate to confirm the suspected diagnosis of ectopic pregnancy?

A. Serum beta-hCG levels and transvaginal ultrasound

B. Abdominal X-ray to assess for fetal positioning

C. Amniocentesis to confirm fetal viability

D. Non-stress test to evaluate fetal heart rate

A. Serum beta-hCG levels and transvaginal ultrasound

Rationale: Ectopic pregnancy is often diagnosed by serial beta-hCG levels and transvaginal ultrasound. A falling or plateaued beta-hCG level and the absence of an intrauterine pregnancy on ultrasound are highly suggestive of ectopic pregnancy.

A nurse is caring for a client diagnosed with an unruptured ectopic pregnancy. The client asks about her treatment options. Which of the following would the nurse include in the teaching?

A. "Surgical removal of the ectopic pregnancy is the only option."

B. "You may receive a medication called methotrexate to stop the growth of the ectopic tissue."

C. "We will monitor the pregnancy with weekly ultrasounds to ensure it does not rupture."

D. "Bed rest and hydration are usually sufficient to manage ectopic pregnancies."

B. "You may receive a medication called methotrexate to stop the growth of the ectopic tissue."

Rationale: Methotrexate is a medical treatment option for early, unruptured ectopic pregnancies. It stops the growth of the ectopic tissue, allowing the body to reabsorb it without surgery. Surgery may be needed if the pregnancy has ruptured or if medical management fails.

A client diagnosed with an ectopic pregnancy suddenly experiences severe shoulder pain and dizziness. Which intervention should the nurse implement immediately?

A. Provide the client with analgesics for pain management.

B. Initiate large-bore IV access and prepare for surgery.

C. Administer oxygen and place the client in a semi-Fowler's position.

D. Encourage the client to lie flat and rest until the pain subsides.

B. Initiate large-bore IV access and prepare for surgery.

Rationale: Severe shoulder pain and dizziness in a client with ectopic pregnancy indicate potential rupture and internal bleeding. The nurse should prioritize stabilizing the client with IV access and preparing for emergency surgery.

A client who has undergone treatment for a ruptured ectopic pregnancy asks the nurse about future fertility. What is the most appropriate response?

A. "You should be able to conceive without any issues after healing."

B. "Ectopic pregnancies do not affect future fertility as long as the remaining tube is healthy."

C. "Having an ectopic pregnancy increases the risk of future ectopic pregnancies."

D. "You will not be able to conceive naturally after a ruptured ectopic pregnancy."

C. "Having an ectopic pregnancy increases the risk of future ectopic pregnancies."

Rationale: A history of ectopic pregnancy increases the risk of future ectopic pregnancies due to potential damage or scarring of the fallopian tubes. Future fertility may be impacted depending on the extent of the damage, but conception may still be possible.

A client at 10 weeks gestation presents with dark brown vaginal discharge, severe nausea, and a uterus larger than expected for gestational age. What is the most likely cause of her symptoms?

A. Normal pregnancy with increased uterine growth

B. Ectopic pregnancy

C. Molar pregnancy

D. Missed miscarriag

C. Molar pregnancy

Rationale: Dark brown vaginal discharge (often described as "prune juice"), severe nausea, and an abnormally large uterus are hallmark signs of a molar pregnancy. Molar pregnancies involve abnormal trophoblastic tissue growth and require further evaluation.

A nurse is educating a client diagnosed with a molar pregnancy about the condition. Which statement by the client indicates a correct understanding of the disease?

A. "Molar pregnancy means that my baby has a genetic disorder."

B. "This condition occurs when the placenta develops abnormally without a viable fetus."

C. "I will need to avoid pregnancy for 6 months after the treatment."

D. "There is no need for follow-up after treatment, as the condition is fully resolved."

B. "This condition occurs when the placenta develops abnormally without a viable fetus."

Rationale: Molar pregnancy occurs when there is abnormal growth of trophoblastic tissue in the placenta, leading to a nonviable pregnancy. Follow-up care is essential to monitor for gestational trophoblastic disease, and pregnancy should generally be avoided for 6-12 months.

A client is undergoing a dilation and curettage (D&C) for a molar pregnancy. Which post-procedure instruction should the nurse prioritize?

A. "You should use tampons to monitor for post-procedure bleeding."

B. "Monitor for signs of infection and return if you experience fever or foul-smelling discharge."

C. "You can resume sexual activity as soon as you feel comfortable."

D. "It's safe to conceive as soon as you have your first normal menstrual cycle."

B. "Monitor for signs of infection and return if you experience fever or foul-smelling discharge."

Rationale: After a D&C, it is important for the client to monitor for signs of infection, such as fever or foul-smelling discharge. The client should avoid using tampons, refrain from sexual activity for a period of time, and delay pregnancy until advised by the healthcare provider.

A nurse is providing discharge teaching for a client who had a molar pregnancy. Which statement would be most important for the nurse to include?

A. "You should return for weekly beta-hCG tests to monitor hormone levels."

B. "You can stop follow-up appointments once you feel physically recovered."

C. "If you experience heavy bleeding, call the office to reschedule your next appointment."

D. "Beta-hCG levels will drop naturally, so there's no need for further monitoring."

A. "You should return for weekly beta-hCG tests to monitor hormone levels."

Rationale: After a molar pregnancy, weekly beta-hCG tests are crucial to monitor for gestational trophoblastic neoplasia, a potential complication. A persistent rise in hCG levels may indicate malignant changes requiring further treatment

A client who has been diagnosed with a complete molar pregnancy is asking about future pregnancies. What should the nurse include in the teaching?

A. "You will not be able to conceive after a molar pregnancy."

B. "You may conceive again but should wait at least 6 to 12 months before trying."

C. "A molar pregnancy means your future pregnancies will be high risk."

D. "There is no increased risk of another molar pregnancy in the future."

B. "You may conceive again but should wait at least 6 to 12 months before trying."

Rationale: Clients who have had a molar pregnancy are advised to avoid pregnancy for at least 6 to 12 months, as elevated hCG levels must be monitored to ensure no malignant changes occur. The risk of recurrence is slightly higher but does not automatically make future pregnancies high risk.

A client at 18 weeks gestation presents with painless vaginal pressure and a history of second-trimester losses. What condition should the nurse suspect, and what is the most appropriate nursing action?

A. Suspect placenta previa and instruct the client to rest in the lateral position.

B. Suspect preterm labor and prepare the client for immediate delivery.

C. Suspect premature cervical dilation and prepare the client for possible cerclage placement.

D. Suspect a urinary tract infection and obtain a urine culture.

C. Suspect premature cervical dilation and prepare the client for possible cerclage placement

Rationale: Painless vaginal pressure during the second trimester, especially with a history of prior pregnancy losses, is highly suggestive of premature cervical dilation. Cerclage, a procedure to reinforce the cervix, may be necessary to prevent further dilation.

A nurse is educating a client with a history of premature cervical dilation who is scheduled for a cervical cerclage at 14 weeks gestation. Which statement by the client indicates a need for further teaching?

A. "The cerclage will help prevent my cervix from opening too early."

B. "I will need to avoid heavy lifting and prolonged standing after the procedure."

C. "The cerclage will be removed around 37 weeks to allow me to deliver vaginally."

D. "I won’t need any follow-up care after the cerclage is placed."

D. "I won’t need any follow-up care after the cerclage is placed."

Rationale: After a cerclage is placed, regular follow-up care is essential to monitor cervical integrity and overall pregnancy health. The client should be aware of the need for ongoing medical supervision to prevent complications such as infection or preterm labor.

A pregnant client with a cervical cerclage presents with increased vaginal discharge and lower abdominal cramping. What is the priority nursing action?

A. Reassure the client that increased discharge is normal after cerclage placement.

B. Encourage the client to rest at home and monitor the cramping.

C. Instruct the client to increase fluid intake and reduce activity.

D. Advise the client to seek immediate medical evaluation for signs of preterm labor.

D. Advise the client to seek immediate medical evaluation for signs of preterm labor.

Rationale: Increased vaginal discharge and cramping may be signs of preterm labor or infection following cervical cerclage placement. Immediate medical evaluation is essential to assess for complications and ensure fetal and maternal safety.

A client is admitted for a cervical cerclage due to a history of premature cervical dilation. What postoperative instructions should the nurse provide to reduce the risk of complications?

A. "You should avoid intercourse for the remainder of your pregnancy."

B. "It’s important to stay on complete bed rest until you deliver."

C. "Monitor for signs of infection, such as fever or foul-smelling vaginal discharge."

D. "You will need to avoid all physical activity, including light walking."

C. "Monitor for signs of infection, such as fever or foul-smelling vaginal discharge."

Rationale: After cervical cerclage placement, clients are instructed to monitor for signs of infection, such as fever or foul-smelling discharge, which can lead to pregnancy complications. While some activity may need to be restricted, complete bed rest and total avoidance of activity are not typically required unless specified by the healthcare provider.

A client with a history of premature cervical dilation is 16 weeks pregnant and asks about early signs of cervical insufficiency. What symptom should the nurse instruct the client to report immediately?

A. Mild ankle swelling in the evening

B. Painless vaginal pressure or an increase in vaginal discharge

C. Occasional headaches relieved by rest

D. Morning sickness and mild nausea

B. Painless vaginal pressure or an increase in vaginal discharge

Rationale: Painless vaginal pressure or an increase in vaginal discharge can be early signs of premature cervical dilation. These symptoms should be reported immediately, as early intervention, such as a cervical cerclage, may be needed to prevent pregnancy loss or preterm birth.

A pregnant client at 32 weeks gestation is diagnosed with placenta previa and presents with painless, bright red vaginal bleeding. What is the nurse's priority action?

A. Perform a sterile vaginal examination to assess cervical dilation.

B. Place the client on bed rest and assess fetal heart rate.

C. Administer oxytocin to control the bleeding.

D. Encourage the client to ambulate to promote circulation.

B. Place the client on bed rest and assess fetal heart rate.

Rationale: Painless, bright red vaginal bleeding is a characteristic sign of placenta previa. The nurse should prioritize placing the client on bed rest to prevent further bleeding and assess fetal heart rate for any signs of distress. Vaginal examinations are contraindicated in placenta previa due to the risk of triggering severe hemorrhage.

A nurse is teaching a client with placenta previa about her condition. Which statement by the client indicates a need for further teaching?

A. "I should call my doctor immediately if I notice any bleeding."

B. "I may need a cesarean section if the placenta does not move away from the cervix."

C. "I can continue having intercourse as long as I don’t experience any bleeding."

D. "I need to avoid strenuous activities and prolonged standing."

C. "I can continue having intercourse as long as I don’t experience any bleeding."

Rationale: Intercourse is contraindicated for clients with placenta previa due to the risk of triggering bleeding. The client needs further education on avoiding sexual activity as well as any activities that may cause trauma to the cervix.

A client at 36 weeks gestation with placenta previa asks why she may need a cesarean delivery. What is the best nursing explanation?

A. "A cesarean section is required because you have already started bleeding."

B. "A cesarean delivery may be necessary to prevent excessive bleeding and ensure a safe delivery for your baby."

C. "You will need a cesarean section only if you go into labor before your due date."

D. "Cesarean sections are preferred for all high-risk pregnancies, regardless of the placenta’s position."

B. "A cesarean delivery may be necessary to prevent excessive bleeding and ensure a safe delivery for your baby."

Rationale: In placenta previa, the placenta is abnormally positioned over or near the cervix, which can lead to severe hemorrhage during vaginal delivery. A cesarean section is often recommended to avoid maternal and fetal complications.

A client at 30 weeks gestation is being monitored for placenta previa and asks about signs to report. Which symptom should the nurse advise the client to report immediately?

A. Painless vaginal bleeding

B. Backache and mild abdominal cramping

C. Occasional Braxton Hicks contractions

D. A sudden decrease in fetal movements

A. Painless vaginal bleeding

Rationale: Painless vaginal bleeding is the hallmark symptom of placenta previa and requires immediate medical attention. This could indicate placental separation, which poses serious risks to both the mother and fetus.

A nurse is caring for a client with confirmed placenta previa who has been admitted for observation after a small bleeding episode. Which nursing intervention is most appropriate to prevent further complications?

A. Encourage the client to ambulate frequently to prevent deep vein thrombosis (DVT).

B. Administer a tocolytic agent to suppress contractions.

C. Perform frequent vaginal examinations to assess for cervical changes.

D. Monitor maternal vital signs and fetal heart rate closely.

D. Monitor maternal vital signs and fetal heart rate closely.

Rationale: Close monitoring of maternal vital signs and fetal heart rate is essential in managing placenta previa to detect any signs of hemorrhage or fetal distress. Vaginal exams are contraindicated in cases of placenta previa, as they can exacerbate bleeding.

A client at 34 weeks gestation presents with sudden-onset, severe abdominal pain, and dark red vaginal bleeding. The nurse notes a rigid uterus and signs of fetal distress. What is the priority nursing intervention?

A. Administer pain medication to manage the client’s discomfort.

B. Prepare the client for an immediate cesarean section.

C. Place the client in a lateral position and apply a warm compress to the abdomen.

D. Perform a sterile vaginal exam to assess cervical dilation.

B. Prepare the client for an immediate cesarean section.

Rationale: Severe abdominal pain, dark red vaginal bleeding, and a rigid uterus are classic signs of placental abruption. The priority intervention is preparing the client for an immediate cesarean section due to the risk of significant hemorrhage and fetal distress. Vaginal exams are contraindicated as they may increase the risk of further complications.

A nurse is caring for a client diagnosed with a partial placental abruption. Which assessment finding would indicate that the abruption is worsening?

A. Increasing abdominal pain and uterine tenderness

B. A decrease in the frequency of Braxton Hicks contractions

C. Bright red vaginal bleeding without pain

D. Fetal heart rate of 140 beats per minute with moderate variability

A. Increasing abdominal pain and uterine tenderness

Rationale: Worsening placental abruption is often indicated by increasing abdominal pain, uterine tenderness, and potentially signs of fetal distress. Bright red bleeding without pain is more characteristic of placenta previa, while normal fetal heart rate with moderate variability suggests fetal well-being.

A client with a history of hypertension is at 32 weeks gestation and presents with mild vaginal bleeding and consistent lower back pain. What is the most appropriate initial nursing action?

A. Administer an oxytocin infusion to stop the bleeding.

B. Assess the client’s blood pressure and fetal heart rate.

C. Perform a fundal massage to alleviate the back pain.

D. Encourage the client to rest in a supine position.

B. Assess the client’s blood pressure and fetal heart rate.

Rationale: Clients with hypertension are at higher risk for placental abruption. Mild vaginal bleeding and lower back pain can be early signs. The priority is to assess the client’s blood pressure and fetal heart rate to evaluate for signs of abruption and fetal distress. Administering oxytocin or performing a fundal massage would not be appropriate in this case.

A nurse is educating a client at 28 weeks gestation with risk factors for placental abruption. Which statement by the client indicates a need for further teaching?

A. "I should report any sudden abdominal pain or vaginal bleeding to my doctor right away."

B. "If I notice a decrease in my baby’s movements, I should call my healthcare provider."

C. "Placental abruption only happens during labor, so I don’t need to worry about it now."

D. "Managing my blood pressure will help reduce my risk of placental abruption."

C. "Placental abruption only happens during labor, so I don’t need to worry about it now."

Rationale: Placental abruption can occur at any time during pregnancy, not just during labor. Clients with risk factors, such as hypertension or trauma, need to be vigilant throughout their pregnancy. This client needs further education on the possibility of abruption before labor.

A client is admitted with a suspected placental abruption. Which finding would most likely indicate a concealed (occult) abruption?

A. Bright red vaginal bleeding with no pain

B. Increased uterine size and rigidity without significant external bleeding

C. Continuous lower abdominal pain with regular contractions

D. Gradual onset of back pain and scant vaginal bleeding

B. Increased uterine size and rigidity without significant external bleeding

Rationale: A concealed or occult placental abruption occurs when blood is trapped between the placenta and the uterine wall, causing increased uterine size and rigidity without significant external bleeding. This is a dangerous situation as it can lead to severe internal bleeding without obvious external signs.

A client at 30 weeks gestation presents with uterine contractions every 10 minutes and mild cramping. What is the nurse’s priority action?

A. Perform a sterile vaginal exam to assess for cervical dilation.

B. Administer tocolytics to stop the contractions.

C. Encourage the client to ambulate and change positions.

D. Assess the client’s hydration status and fetal heart rate

D. Assess the client’s hydration status and fetal heart rate

Rationale: Preterm labor can be triggered by dehydration or infection, so assessing the client’s hydration status and fetal heart rate is essential. Administering tocolytics may be appropriate later if the contractions persist. Vaginal exams should be avoided initially, as they can increase the risk of infection.

A nurse is teaching a client at 28 weeks gestation about signs of preterm labor. Which statement by the client indicates a need for further teaching?

A. "I will call my doctor if I feel more than four contractions in an hour."

B. "If I feel pelvic pressure or lower back pain, I should contact my healthcare provider."

C. "If I notice a gush of fluid, I should wait a few hours to see if contractions start."

D. "I will need to monitor for any change in vaginal discharge, especially if it becomes watery or bloody."

C. "If I notice a gush of fluid, I should wait a few hours to see if contractions start."

Rationale: A gush of fluid may indicate rupture of membranes, which requires immediate medical attention. Waiting a few hours would increase the risk of infection or complications. This client needs further education about the urgency of contacting the healthcare provider if any signs of preterm labor occur.

A client diagnosed with preterm labor at 32 weeks gestation is receiving betamethasone. What is the purpose of this medication?

A. To delay labor by stopping uterine contractions

B. To reduce the risk of infection during labor

C. To enhance fetal lung maturity in preparation for potential preterm birth

D. To manage maternal blood pressure and reduce the risk of preeclampsia

C. To enhance fetal lung maturity in preparation for potential preterm birth

Rationale: Betamethasone is administered in cases of preterm labor to accelerate fetal lung maturity and reduce the risk of neonatal respiratory distress syndrome if preterm birth occurs. It does not delay labor or affect maternal blood pressure.

A client with preterm labor is being treated with magnesium sulfate. Which assessment finding would require the nurse to notify the healthcare provider immediately?

A. Maternal respiratory rate of 10 breaths per minute

B. Fetal heart rate of 130 beats per minute with moderate variability

C. Deep tendon reflexes 2+ bilaterally

D. Client reports feeling drowsy after receiving the medication

A. Maternal respiratory rate of 10 breaths per minute

Rationale: A maternal respiratory rate of 10 breaths per minute indicates respiratory depression, a potential side effect of magnesium sulfate toxicity. The healthcare provider should be notified immediately. Fetal heart rate of 130 bpm and 2+ deep tendon reflexes are normal findings.

A nurse is caring for a client at 29 weeks gestation who is in preterm labor. Which intervention should the nurse prioritize to reduce the risk of preterm delivery?

A. Encourage frequent ambulation to reduce discomfort from contractions.

B. Administer prescribed tocolytics and place the client on bed rest.

C. Instruct the client to perform pelvic exercises to strengthen uterine muscles.

D. Provide the client with emotional support and discuss delivery options.

B. Administer prescribed tocolytics and place the client on bed rest.

Rationale: Administering tocolytics to suppress uterine contractions and placing the client on bed rest can help delay preterm labor and reduce the risk of preterm delivery. Ambulation or pelvic exercises would not be appropriate in this situation, as they could exacerbate contractions.

A client at 32 weeks gestation presents to the hospital with a sudden gush of fluid from the vagina. The nurse suspects preterm premature rupture of membranes (PPROM). What is the nurse’s priority action?

A. Perform a sterile vaginal examination to confirm cervical dilation.

B. Collect a sample of the fluid for a nitrazine or fern test.

C. Encourage the client to ambulate to encourage labor progression.

D. Administer oxytocin to initiate labor.

B. Collect a sample of the fluid for a nitrazine or fern test.

Rationale: When PPROM is suspected, the nurse should confirm the presence of amniotic fluid using a nitrazine or fern test. Vaginal exams are contraindicated to reduce the risk of infection, and ambulation or oxytocin administration would not be appropriate before confirming the diagnosis and assessing fetal well-being.

A client with PPROM at 30 weeks gestation asks why she is being placed on antibiotics. What is the nurse’s best response?

A. "The antibiotics will help prevent infection, which is a common complication after your membranes rupture."

B. "The antibiotics will stop your contractions and delay labor."

C. "Antibiotics will help improve fetal lung maturity before delivery."

D. "Antibiotics are given to prevent fetal heart rate abnormalities."

A. "The antibiotics will help prevent infection, which is a common complication after your membranes rupture."

Rationale: PPROM increases the risk of infection for both the mother and the fetus, particularly chorioamnionitis. Antibiotics are given to prevent infection after the rupture of membranes. They do not directly affect labor, fetal lung maturity, or fetal heart rate abnormalities.

A client with PPROM at 31 weeks gestation asks how long she will need to stay in the hospital. What is the nurse's best response?

A. "You will stay in the hospital until you reach 37 weeks gestation."

B. "You will remain in the hospital until your contractions become regular."

C. "You will be monitored in the hospital until delivery, which may be soon depending on your condition and any signs of infection or labor."

D. "You will be discharged within a few days as long as the fluid leakage stops."

C. "You will be monitored in the hospital until delivery, which may be soon depending on your condition and any signs of infection or labor."

Rationale: Clients with PPROM are typically monitored in the hospital for signs of labor, infection, or fetal distress. The length of stay depends on the clinical situation, as delivery may need to be expedited if complications arise. There is no guarantee the client will stay until 37 weeks or be discharged soon.

A client at 33 weeks gestation with PPROM asks why she is receiving corticosteroids. What is the nurse’s most appropriate explanation?

A. "Corticosteroids help reduce the risk of infection in the amniotic fluid."

B. "The medication will help your baby’s lungs mature in case of early delivery."

C. "Corticosteroids will stop any contractions you are having to delay labor."

D. "The medication is used to increase the production of amniotic fluid.

B. "The medication will help your baby’s lungs mature in case of early delivery."

Rationale: Corticosteroids, such as betamethasone, are given to accelerate fetal lung maturity and reduce the risk of respiratory complications if preterm birth occurs. They do not prevent labor or increase amniotic fluid levels.

A nurse is caring for a client at 29 weeks gestation who has been diagnosed with PPROM. Which assessment finding would indicate a possible complication that requires immediate intervention?

A. Fetal heart rate of 140 beats per minute with moderate variability

B. Maternal temperature of 101.2°F (38.4°C)

C. Clear amniotic fluid leaking from the vagina

D. Mild uterine cramping and irregular contraction

B. Maternal temperature of 101.2°F (38.4°C)

Rationale: A maternal temperature of 101.2°F (38.4°C) suggests infection, such as chorioamnionitis, which is a serious complication of PPROM that requires immediate intervention. A normal fetal heart rate, clear amniotic fluid, and mild cramping are expected findings in PPROM.

A client at 39 weeks gestation presents with rupture of membranes but no uterine contractions. The nurse explains the plan of care, which includes labor induction. What is the primary reason for inducing labor in this case?

A. To prevent infection in the mother and fetus

B. To decrease the risk of postpartum hemorrhage

C. To avoid fetal macrosomia and complications with delivery

D. To speed up the labor process for the mother’s comfor

A. To prevent infection in the mother and fetus

Rationale: Once the membranes rupture, the risk of infection (e.g., chorioamnionitis) increases. Labor induction is often initiated to reduce the risk of infection in both the mother and fetus if labor does not start spontaneously.

A nurse is caring for a client at 37 weeks gestation who has been diagnosed with PROM. The client asks how long it will take for labor to start. What is the nurse’s best response?

A. "Labor typically starts within 24 hours after your membranes rupture."

B. "It is hard to predict, but we will wait until contractions begin naturally."

C. "You will need a cesarean section if labor does not start within the next few hours."

D. "You will be given medications to stop labor from starting too soon."

A. "Labor typically starts within 24 hours after your membranes rupture."

Rationale: Labor typically begins within 24 hours of membrane rupture, especially in term pregnancies. If labor does not start naturally, induction may be considered to reduce the risk of infection. A cesarean section is not automatically required in this case.

A client at 36 weeks gestation with a history of PROM is admitted for monitoring. Which nursing intervention is most appropriate to reduce the risk of infection?

A. Encourage frequent ambulation to promote circulation.

B. Limit vaginal examinations unless medically necessary.

C. Administer oxytocin to accelerate the onset of labor.

D. Perform hourly temperature checks to assess for fever.

B. Limit vaginal examinations unless medically necessary.

Rationale: Limiting vaginal examinations is essential to reduce the risk of infection in clients with PROM. Repeated vaginal exams can introduce bacteria into the uterus. Frequent temperature monitoring and oxytocin administration may be appropriate depending on the clinical situation, but minimizing exams is crucial to infection prevention.

A client at 38 weeks gestation with PROM is being prepared for labor induction. Which fetal assessment should the nurse prioritize before administering oxytocin?

A. Fetal position

B. Fetal heart rate and pattern

C. Estimated fetal weight

D. Fetal movement count

B. Fetal heart rate and pattern

Rationale: Before administering oxytocin to induce labor, it is essential to assess fetal heart rate and patterns to ensure fetal well-being and to rule out any signs of distress. Fetal position and weight are important but not the priority at this stage, and fetal movement is typically monitored by the client at home.

A nurse is caring for a client at 39 weeks gestation who has been diagnosed with chorioamnionitis. The client has a temperature of 101.8°F (38.8°C), fetal tachycardia, and purulent amniotic fluid. What is the nurse’s priority action?

A. Administer prescribed broad-spectrum antibiotics.

B. Increase intravenous fluid administration to lower the fever.

C. Perform a sterile vaginal exam to assess for labor progression.

D. Administer antipyretics to reduce maternal temperature.

A. Administer prescribed broad-spectrum antibiotics.

Rationale: The priority intervention for a client with chorioamnionitis is to administer broad-spectrum antibiotics to treat the infection and reduce the risk of complications. While antipyretics and IV fluids may be used to manage fever, addressing the underlying infection is the most critical action. Vaginal exams should be minimized due to the risk of worsening infection.

A client at 40 weeks gestation with prolonged rupture of membranes is diagnosed with chorioamnionitis. Which fetal assessment finding is most concerning and requires immediate intervention?

A. Fetal heart rate of 160 beats per minute

B. Fetal heart rate of 200 beats per minute with minimal variability

C. Accelerations in fetal heart rate with contractions

D. Moderate variability in fetal heart rate

B. Fetal heart rate of 200 beats per minute with minimal variability

Rationale: A fetal heart rate of 200 beats per minute with minimal variability is a sign of fetal tachycardia and distress, which can occur in the presence of chorioamnionitis. This requires immediate intervention. A heart rate of 160 bpm and moderate variability are within normal limits for a term fetus.

A nurse is providing discharge teaching to a postpartum client who was treated for chorioamnionitis during labor. Which statement by the client indicates a need for further teaching?

A. "I will continue taking the prescribed antibiotics until they are finished."

B. "I should monitor for signs of infection, such as fever or foul-smelling vaginal discharge."

C. "I don’t need to worry about complications now that I’ve delivered my baby."

D. "I will watch for signs of infection in my baby, such as poor feeding or lethargy."

C. "I don’t need to worry about complications now that I’ve delivered my baby."

Rationale: Chorioamnionitis can lead to postpartum complications for both the mother and the newborn, including endometritis and neonatal infections. The client needs further teaching to understand that monitoring for signs of infection in both herself and her baby is essential even after delivery.

A nurse is monitoring a client at 34 weeks gestation diagnosed with gestational hypertension. The client’s blood pressure is 150/95 mmHg, and she reports a severe headache and visual disturbances. What is the nurse’s priority intervention?

A. Administer the prescribed antihypertensive medication.

B. Perform a nonstress test to assess fetal well-being.

C. Prepare the client for possible delivery based on symptoms.

D. Encourage the client to rest in a comfortable position.

C. Prepare the client for possible delivery based on symptoms.

The combination of severe headache, visual disturbances, and high blood pressure may indicate the onset of severe gestational hypertension or preeclampsia, which could necessitate immediate delivery to prevent further complications for both the mother and the fetus. While antihypertensive medication and fetal monitoring are important, the priority is preparing for possible delivery based on the client's critical symptoms.

A client with gestational hypertension is being educated about lifestyle modifications to manage her condition. Which statement by the client indicates a need for further teaching?

A. "I should reduce my salt intake to help control my blood pressure."

B. "I can continue my regular exercise routine, as long as I feel okay."

C. "I need to monitor my blood pressure at home and keep a log of the readings."

D. "It’s important for me to stay well-hydrated, even if I have high blood pressure."

D. "It’s important for me to stay well-hydrated, even if I have high blood pressure."

Rationale: While hydration is important, excessive fluid intake can lead to increased blood volume and worsen hypertension. Clients with gestational hypertension should be educated on appropriate fluid intake. The other statements reflect appropriate understanding of lifestyle modifications needed to manage gestational hypertension.

A nurse is reviewing the lab results of a client diagnosed with gestational hypertension. Which laboratory finding would be most concerning and indicative of potential complications?

A. Elevated liver enzymes (AST and ALT)

B. Normal platelet count

C. Proteinuria of 1+ on a dipstick test

D. Glucose level within normal limits

A. Elevated liver enzymes (AST and ALT)

Rationale: Elevated liver enzymes can indicate liver involvement, which may suggest progression to severe preeclampsia or HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count). This is a concerning finding that requires further evaluation and potential intervention. Normal platelet counts and mild proteinuria are less alarming compared to elevated liver enzymes.

A nurse is caring for a client diagnosed with HELLP syndrome. Which assessment finding should the nurse prioritize when monitoring the client?

A. Blood pressure of 130/80 mmHg

B. Abdominal pain in the right upper quadrant

C. Fetal heart rate of 140 beats per minute

D. Mild edema in the lower extremities

B. Abdominal pain in the right upper quadrant

Rationale: Right upper quadrant abdominal pain is a classic symptom of HELLP syndrome and may indicate liver distension or rupture. This finding requires immediate assessment and potential intervention, as it can signify worsening of the condition.

A nurse is preparing to administer magnesium sulfate to a client diagnosed with HELLP syndrome. Which assessment finding should prompt the nurse to hold the medication and notify the healthcare provider?

A. Respiratory rate of 16 breaths per minute

B. Deep tendon reflexes of 3+ bilaterally

C. Urine output of 25 mL/hour

D. Serum magnesium level of 5.5 mg/d

C. Urine output of 25 mL/hour

Rationale: A urine output of 25 mL/hour is indicative of potential renal impairment and could signal magnesium toxicity, requiring the nurse to hold the magnesium sulfate and notify the healthcare provider. Normal respiratory rates and deep tendon reflexes do not warrant holding the medication at this time, and a magnesium level of 5.5 mg/dL is within the therapeutic range.

A nurse is educating a client with HELLP syndrome about potential complications. Which statement by the client indicates a need for further teaching?

A. "I understand that HELLP syndrome can lead to liver failure and bleeding."

B. "I'm aware that this condition can affect my baby’s growth and development."

C. "I can continue my normal activities as long as I feel okay."

D. "I should report any severe headaches or vision changes immediately."

C. "I can continue my normal activities as long as I feel okay."

Rationale: Clients with HELLP syndrome should limit activities and closely monitor their health status due to the risk of severe complications. Continuing normal activities without caution indicates a lack of understanding about the seriousness of the condition. The other statements reflect an appropriate understanding of potential complications.

A nurse is monitoring the lab results of a client with HELLP syndrome. Which laboratory finding would most likely indicate worsening of the condition?

A. Platelet count of 150,000/mm³

B. Serum creatinine level of 0.8 mg/dL

C. Aspartate aminotransferase (AST) of 250 IU/L

D. Hemoglobin level of 12 g/d

C. Aspartate aminotransferase (AST) of 250 IU/L

Rationale: An elevated AST level (250 IU/L) is indicative of liver dysfunction, which is a key component of HELLP syndrome. A normal platelet count and serum creatinine level are not concerning, and a hemoglobin level of 12 g/dL is within normal limits.

A client diagnosed with HELLP syndrome is being prepared for an emergency cesarean section. What is the nurse's priority action before the procedure?

A. Administer preoperative antibiotics as prescribed.

B. Obtain informed consent from the client and family.

C. Ensure the client has not eaten for at least 8 hours.

D. Administer magnesium sulfate to prevent seizures.

B. Obtain informed consent from the client and family.

Rationale: Obtaining informed consent is a legal and ethical requirement before any surgical procedure, including a cesarean section. While administering antibiotics and magnesium sulfate are important, ensuring informed consent takes priority in preparation for surgery. Ensuring fasting status is also essential but secondary to the consent process.

A nurse is caring for a client who experienced fetal demise at 20 weeks gestation. Which nursing intervention is most appropriate to provide emotional support for the client and her partner?

A. Encourage the couple to forget about the loss and focus on the next pregnancy.

B. Provide resources for support groups and counseling services.

C. Suggest that they should not discuss their feelings to avoid further pain.

D. Reassure them that they can try for another baby soon.

B. Provide resources for support groups and counseling services.

Rationale: Providing resources for support groups and counseling services offers the couple avenues for emotional processing and coping with their loss. Encouraging them to forget about the loss or suppress their feelings is not supportive and can hinder the grieving process. While future pregnancies can be discussed, it is important to focus on their current emotional needs first.

A nurse is discussing the plan of care for a client who has just been diagnosed with fetal demise at 28 weeks gestation. Which statement by the client indicates a need for further education regarding the management of her condition?

A. "I understand that I may need to deliver my baby soon."

B. "I should monitor my temperature and report any fever to my healthcare provider."

C. "I can take over-the-counter pain relievers to manage any discomfort."

D. "I will be provided with options for labor induction and delivery."

C. "I can take over-the-counter pain relievers to manage any discomfort."

Rationale: While the client may experience discomfort, over-the-counter pain relievers may not be appropriate, especially without healthcare provider guidance, as they can have risks or contraindications during this sensitive time. The other statements reflect an understanding of the necessary steps in managing fetal demise, including monitoring for infection and understanding delivery options.

A nurse is assessing a client who has experienced fetal demise. Which assessment finding should prompt the nurse to notify the healthcare provider immediately?

A. Maternal heart rate of 90 beats per minute

B. Decreased fetal movement noted on assessment

C. Dark red vaginal bleeding with cramping

D. Emotional distress and crying

C. Dark red vaginal bleeding with cramping

Rationale: Dark red vaginal bleeding accompanied by cramping could indicate complications such as a potential miscarriage or hemorrhage, which requires immediate medical evaluation. While emotional distress is expected after fetal demise and decreased fetal movement indicates a loss, the presence of dark red bleeding is a critical concern that warrants prompt attention.

A nurse is caring for a client who is 42 weeks pregnant and has been diagnosed with postterm pregnancy. Which assessment finding would be most concerning and warrant immediate intervention?

A. Fetal heart rate of 130 beats per minute with moderate variability

B. Oligohydramnios noted on ultrasound

C. Maternal blood pressure of 120/70 mmHg

D. Mild cramping and irregular contractions

B. Oligohydramnios noted on ultrasound

Rationale: Oligohydramnios (low amniotic fluid) is a concerning finding in postterm pregnancy as it can indicate placental insufficiency and may increase the risk of complications for the fetus. While a normal fetal heart rate and maternal blood pressure are reassuring, mild cramping is expected as the body prepares for labor.

A client at 41 weeks gestation is being prepared for an induction of labor due to postterm pregnancy. The nurse explains the induction process. Which client statement indicates a need for further education?

A. "I understand that my cervix will need to be ripe for induction to be successful."

B. "I know that induction can help prevent complications for my baby."

C. "I can still have a vaginal delivery after an induction."

D. "I might not need an induction if my body goes into labor on its own."

D. "I might not need an induction if my body goes into labor on its own."

Rationale: While it’s true that clients with postterm pregnancy may still go into labor naturally, stating that she "might not need an induction" implies a lack of understanding about the standard practice for postterm pregnancies. Induction is often recommended due to the increased risks associated with prolonged gestation. The other statements indicate a proper understanding of the induction process.

A nurse is discussing the risks associated with postterm pregnancy with a client who is 42 weeks gestation. Which risk factor should the nurse emphasize as a primary concern?

A. Increased likelihood of cesarean delivery

B. Increased risk of postpartum hemorrhage

C. Decreased fetal movement

D. Higher chances of preterm labor

A. Increased likelihood of cesarean delivery

Rationale: The primary concern in postterm pregnancy is the increased likelihood of cesarean delivery due to factors such as fetal size (macrosomia) and potential fetal distress. While postpartum hemorrhage and decreased fetal movement can also be concerns, they are not as directly linked to the specific risks of postterm pregnancy as the increased rate of cesarean deliveries.

A nurse is assessing a newborn who has just transitioned to extrauterine life. Which finding would indicate that the infant is effectively adapting to the new environment?

A. Grunting with every breath

B. Heart rate fluctuating between 100-180 beats per minute

C. Respiratory rate of 60 breaths per minute with retractions

D. Pink skin color with acrocyanosis

D. Pink skin color with acrocyanosis

Rationale: A pink skin color with acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns adapting to extrauterine life, as they may have transient cyanosis of the extremities while the trunk remains pink. The other options indicate potential respiratory distress or abnormal heart rate patterns.

A nurse is performing a newborn assessment. Which finding indicates the newborn may be experiencing difficulty with thermoregulation?

A. Temperature of 98.1°F

B. Active movement and crying

C. Bluish discoloration of the extremities

D. Pink and well-perfused skin

C. Bluish discoloration of the extremities

Rationale: Acrocyanosis, or a bluish discoloration of the extremities, can indicate issues with temperature regulation in a newborn. Newborns have an immature thermoregulatory system and are susceptible to heat loss.

A newborn has an Apgar score of 5 at one minute. What is the nurse's priority action?

A. Notify the provider immediately.

B. Perform a head-to-toe physical assessment.

C. Provide resuscitation and reassess at five minutes.

D. Delay interventions and observe the newborn

C. Provide resuscitation and reassess at five minutes.

Rationale: An Apgar score of 5 indicates moderate difficulty with transitioning to extrauterine life. Immediate resuscitative measures, such as providing oxygen and maintaining warmth, should be initiated, followed by a reassessment at five minutes.

During a newborn physical assessment, the nurse notices the newborn has caput succedaneum. How should the nurse document this finding?

A. An abnormal swelling under the scalp caused by bleeding

B. A normal finding of soft tissue swelling over the cranial suture lines

C. An abnormal finding indicating skull fracture

D. An indication for immediate neurological imaging

B. A normal finding of soft tissue swelling over the cranial suture lines

Rationale: Caput succedaneum is a common and benign condition in which there is swelling of the soft tissues of the scalp that crosses suture lines, usually resulting from pressure during birth.

A nurse is teaching new parents about umbilical cord care. Which statement indicates a need for further teaching?

A. "We should keep the umbilical cord dry and exposed to air."

B. "We can apply alcohol to the base of the cord after each diaper change."

C. "The cord should fall off within one to two weeks."

D. "We will fold the diaper down to prevent irritation to the cord."

B. "We can apply alcohol to the base of the cord after each diaper change."

Rationale: Routine application of alcohol to the umbilical cord is generally no longer recommended, as keeping the area dry promotes faster healing. The other statements correctly reflect best practices for cord care.

A nurse is monitoring a newborn's vital signs. Which of the following findings should be reported to the provider?

A. Respiratory rate of 42 breaths per minute

B. Heart rate of 132 beats per minute

C. Temperature of 97.2°F

D. Blood pressure of 70/45 mm Hg

C. Temperature of 97.2°F

Rationale: A temperature of 97.2°F may indicate that the newborn is experiencing hypothermia, which can affect glucose metabolism and increase energy demands. Newborns should be kept warm to prevent heat loss.

A nurse is performing an APGAR assessment on a newborn one minute after birth. The newborn has a heart rate of 130 beats per minute, cries vigorously, pulls away when the nurse attempts suctioning, flexes all extremities, and is pink with blue hands and feet. What APGAR score should the nurse assign?

A. 8

B. 9

C. 7

D. 6

B. 9

Rationale: The newborn receives a score of 2 for heart rate (over 100 bpm), 2 for respiratory effort (crying), 2 for muscle tone (well-flexed), 1 for color (pink with acrocyanosis), and 2 for reflex irritability (crying and pulling away). Total score = 9.

A newborn has an APGAR score of 4 at one minute. Which of the following actions should the nurse prioritize?

A. Continue monitoring and reassess the APGAR score at five minutes.

B. Transfer the newborn to the NICU immediately.

C. Begin immediate resuscitation, including oxygen support as needed.

D. Notify the healthcare provider and prepare for an emergency intervention.

C. Begin immediate resuscitation, including oxygen support as needed.

Rationale: An APGAR score of 4 indicates moderate to severe distress, requiring immediate intervention. Resuscitative measures, such as oxygen support, should begin right away, followed by reassessment at five minutes.

At five minutes after birth, a newborn has an APGAR score of 5. Which interventions should the nurse implement?

A. Document the findings and provide routine care.

B. Continue resuscitation efforts and reassess every five minutes.

C. Notify the healthcare provider to initiate phototherapy.

D. Encourage breastfeeding to improve oxygen saturatio

B. Continue resuscitation efforts and reassess every five minutes.

Rationale: An APGAR score of 5 at five minutes indicates moderate distress, so resuscitation should continue, and the APGAR should be reassessed every five minutes until the score stabilizes at 7 or higher.

Which component of the APGAR score reflects the newborn's response to suctioning or mild stimulation?

A. Respiratory effort

B. Reflex irritability

C. Muscle tone

D. Heart rate

B. Reflex irritability

Rationale: Reflex irritability assesses the newborn's response to gentle stimuli, such as suctioning or tapping on the soles of the feet. A strong response is indicative of a healthy nervous system.

During an APGAR assessment, a newborn scores 1 for respiratory effort, 2 for heart rate, 1 for muscle tone, 1 for color, and 0 for reflex irritability. Which of the following nursing diagnoses is most appropriate based on this score?

A. Ineffective Thermoregulation related to immature hypothalamic response

B. Ineffective Breathing Pattern related to respiratory distress

C. Risk for Injury related to low birth weight

D. Ineffective Feeding Pattern related to weak suck reflex

B. Ineffective Breathing Pattern related to respiratory distress

Rationale: With an APGAR score indicating poor respiratory effort and reflex irritability, the primary concern is respiratory distress, making "Ineffective Breathing Pattern" the most appropriate diagnosis.

A new mother is concerned that her milk has not come in immediately after birth and wants to supplement with formula. What is the best response by the nurse?

A. "Your body will begin producing milk as soon as you begin using formula."

B. "Colostrum, which your body is producing now, is sufficient to meet your baby’s needs."

C. "You should avoid breastfeeding until your milk comes in to prevent confusion."

D. "It’s essential to wait until the mature milk comes in before breastfeeding."

B. "Colostrum, which your body is producing now, is sufficient to meet your baby’s needs."

Rationale: Colostrum is highly nutritious and provides the newborn with essential antibodies and nutrients, which is sufficient for the baby’s needs in the first few days until mature milk production begins.

A nurse is educating new parents on signs of adequate hydration in their newborn. Which indicator should the nurse emphasize?

A. Crying after feedings

B. Wetting six to eight diapers daily

C. Sleeping for only 1-2 hours between feedings

D. Losing more than 10% of birth weight by day three

B. Wetting six to eight diapers daily

Rationale: Six to eight wet diapers per day is a strong indicator that the newborn is receiving adequate hydration, reflecting proper intake and kidney function.

During discharge teaching, a mother asks about storing breast milk. Which instruction should the nurse provide to ensure safe storage?

A. "Refrigerate expressed breast milk for up to 24 hours."

B. "Keep breast milk in the freezer for no more than one week."

C. "Thaw frozen milk in the microwave to speed up feeding times."

D. "Store freshly pumped milk in the refrigerator for up to four days."

D. "Store freshly pumped milk in the refrigerator for up to four days."

Rationale: Freshly pumped breast milk can be safely stored in the refrigerator for up to four days. Microwaving breast milk is discouraged as it can cause uneven heating and destroy nutrients.

A mother who plans to return to work asks about techniques to maintain her milk supply while separated from her baby. Which recommendation should the nurse make?

A. "Try to gradually reduce feedings to help your body adjust."

B. "Pump as frequently as your baby would normally feed."

C. "Limit pumping to once in the morning and once at night."

D. "Wait to pump until you start to feel engorged."

B. "Pump as frequently as your baby would normally feed."

Rationale: Pumping at the same frequency as normal feeding times helps maintain milk production, as milk supply depends on regular removal to stimulate ongoing production.