Maternal Newborn Practice Quiz 1 & 2

A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Betamethasone

Misoprostol

Methylergonovine

Poractant alfa

Betamethasone

The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression.

---

The nurse should administer misoprostol to stimulate uterine contractions for a client who is undergoing labor induction.

The nurse should administer methylergonovine to stimulate uterine contractions for a client who is experiencing postpartum hemorrhage.

The nurse should administers poractant alfa, a synthetic lung surfactant, to a preterm newborn who is experiencing respiratory distress.

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy?

A blood test for the presence of estrogen

A blood test for the amount of circulating progesterone

A urine test for the presence of human chorionic somatomammotropin

A urine test for the presence of human chorionic gonadotropin

A urine test for the presence of human chorionic gonadotropin

Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing.

---

Progesterone is a hormone critical to pregnancy. However, it is not the basis for pregnancy testing.

The female ovaries produce estrogen whether a woman is pregnant or not.

Human somatomammotropin is a placental hormone. However, its presence does not confirm pregnancy.

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?

Palpable fetal movement

Chadwick's sign

Positive pregnancy test

Amenorrhea

Palpable fetal movement

Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy.

---

Chadwick’s sign is a bluish discoloration in the cervix, vagina, and vulva that occurs at 6 to 8 weeks. This is a probable sign of pregnancy. After the client's first pregnancy, this discoloration can remain, making it of little value as an indicator in subsequent pregnancies.

A positive pregnancy test is a probable sign of pregnancy. A client can also have a positive pregnancy test due to menopause, choriocarcinoma, and hydatidiform mole.

Amenorrhea, or lack of a menstrual period, is a presumptive sign of pregnancy. A client can have amenorrhea due to stress, endocrine disorders, and significant weight loss.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?

Atrial septal defect

Renal agenesis

Spina bifida

Hydrocephalus

Renal agenesis

Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy.

Absence of fetal kidneys will cause oligohydramnios.

Since amniotic fluid is primarily composed of fetal urine after the first trimester, a fetal genitourinary anomaly, such as renal agenesis (failure of kidney development), is a major cause.

Potter syndrome, which includes bilateral renal agenesis, pulmonary hypoplasia, and limb deformities, is a classic example associated with oligohydramnios.

---

Fetal cardiac anomalies do not affect the volume of amniotic fluid.

Fetal neural tube defects do not affect the volume of amniotic fluid.

Fetal hydrocephalus does not affect the volume of amniotic fluid.

A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect?

Bradycardia

Uterine contractions

Seizures

Bradypnea

Uterine contractions

• Blunt abdominal trauma (e.g., from a motor vehicle accident or fall) can cause uterine irritation, placental abruption, or preterm labor, leading to uterine contractions.

• At 37 weeks gestation, trauma can stimulate the uterus to contract, increasing the risk of preterm labor or fetal distresss

A nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following findings should the nurse expect?

Hypothermia

Dark brown vaginal discharge

Decreased urinary output

Fetal heart tones

Dark brown vaginal discharge

A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?

480 mL urine output in 24 hr

Blood pressure 144/92 mm Hg

+2 edema of the feet

1+ protein in the urine

480 mL urine output in 24 hr

Minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.

A nurse is teaching a client who is at 12 weeks of gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?

"Breastfeed your newborn to provide passive immunity."

"Abstain from sexual intercourse throughout the pregnancy."

"You will be in isolation after delivery."

"You should continue to take zidovudine throughout the pregnancy."

"You should continue to take zidovudine throughout the pregnancy."

The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.

---

The nurse should tell the client that she can transmit HIV through breast milk. Therefore, the client should bottle feed her newborn.

A nurse is providing teaching to a client who is at 8 weeks of gestation about manifestations to report to the provider during pregnancy. Which of the following information should the nurse include in the teaching?

Nausea upon awakening

Leg cramps when sleeping

Increase in white vaginal discharge

Blurred or double vision

Blurred or double vision

A client who is pregnant should report experiencing blurred or double vision as these could be a manifestation of gestation hypertension or pre-eclampsia.

---

A client who is pregnant can have an increase in vaginal discharge due to the cervix becoming hyperstimulated from an increase in hormones.

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100 to 110 seconds and that the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take?

Decrease the infusion rate of the maintenance IV fluid.

Administer oxygen via nonrebreather mask.

Decrease the dose of oxytocin by half.

Administer terbutaline 0.25 mg subcutaneously.

Decrease the dose of oxytocin by half.

The client is experiencing tachysystole (excessive uterine contractions), defined as:

• More than 5 contractions in 10 minutes

• Contractions lasting longer than 90 seconds

• Inadequate uterine relaxation between contractions

---

Oxygen is used when there are signs of fetal distress (e.g., late decelerations, bradycardia), but in this case, the FHR is reassuring.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse take?

Prepare the client for an ultrasound examination.

Prepare the client for an emergency cesarean birth.

Prepare equipment needed for newborn resuscitation.

Perform endotracheal suctioning as soon as the fetal head is delivered.

Prepare equipment needed for newborn resuscitation.

The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery.

---

The nurse does not need to prepare the client for an emergency cesarean due to meconium-stained amniotic fluid.

Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?

Perform a vaginal examination.

Perform continuous external fetal monitoring.

Insert a large-bore IV catheter.

Obtain a blood sample for laboratory testing.

Perform a vaginal examination.

When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.

A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take?

Use vibroacoustic stimulation on the client's abdomen for 3 seconds.

Report the nonreactive test result to the provider immediately.

Request a prescription for an internal fetal scalp electrode.

Auscultate the FHR with a Doppler transducer.

Use vibroacoustic stimulation on the client's abdomen for 3 seconds.

The nurse should use a vibroacoustic stimulator on the client’s abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.

---

The nurse will determine a nonstress test to be nonreactive after 40 min of continuous monitoring without accelerations in the FHR despite vibroacoustic stimulation.

The client should have an internal fetal scalp electrode during labor to monitor the FHR.

A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type of O negative. Which of the following actions should the nurse take?

Administer a dose of Rho(D) immune globulin.

Request a prescription for an antibiotic until delivery.

Instruct the client to obtain a rubella immunization after delivery.

Inform the client that she will need to deliver via cesarean birth.

Instruct the client to obtain a rubella immunization after delivery.

This client is not immune to rubella and should receive this immunization after delivery.

---

The client will receive IV antibiotic therapy during labor to prevent transmission of group B beta-hemolytic streptococcus to the newborn.

A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which of the following findings should the nurse expect?

Fundal height of 34 cm (13.4 in)

Total pregnancy weight gain of 3.6 kg (8 lb)

Gestational hypertension

Fetal gastrointestinal anomaly

Fetal gastrointestinal anomaly

Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

---

Polyhydramnios is not directly linked to gestational hypertension (GH).

Gestational hypertension is more commonly associated with oligohydramnios due to poor placental perfusion.

A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?

Elevated blood pressure

Feeling of warmth

Hyperactivity

Generalized pruritus

Feeling of warmth

• Magnesium sulfate is administered intravenously to prevent seizures (eclampsia) in clients with preeclampsia.

• Common expected side effects include:

  • Feeling of warmth/flushing (due to vasodilation)

  • Diaphoresis (sweating)

  • Mild hypotension

  • Sedation/lethargy

  • Muscle weakness

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?

Instruct the client to pant during contractions.

Position the client supine with legs elevated.

Encourage the client to soak in a warm bath.

Apply pressure to the client's sacral area during contractions.

Apply pressure to the client's sacral area during contractions.

• Low back pain during labor is often caused by fetal occiput posterior position or pressure on the sacral nerves.

• Sacral counterpressure (firm pressure on the lower back) helps relieve pain by counteracting the pressure of the fetal head.

---

The nurse should not place the client supine during labor because this will increase her back pain.

A nurse is teaching a client who is at 12 weeks of gestation about manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching?

Swelling of the face

Urinary frequency

White vaginal discharge

Intermittent nausea

Swelling of the face

The nurse should instruct the client to report swelling of the face because this can indicate a hypertensive disorder or preeclampsia.

---

White vaginal discharge is an expected finding during pregnancy resulting from high levels of estrogen. The client should only report this finding if the discharge becomes foul-smelling or changes color.

A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching?

"You will have a nonstress test prior to the ultrasound."

"You will need to have a full bladder during the ultrasound."

"The ultrasound will determine the length of your cervix."

"You will experience uterine cramping during the ultrasound."

"You will need to have a full bladder during the ultrasound."

The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.

---

The client can have a nonstress test after 26 weeks of gestation to determine fetal well-being.

The client can have a transvaginal ultrasound to measure cervical length in the second and third trimesters to assess for preterm labor.

A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of the following findings should the nurse expect?

Increased platelet count

Fetal distress

Decreased urinary output

Dark red vaginal bleeding

Dark red vaginal bleeding

The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.

---

The nurse should expect the client who has a mild placental abruption to have a reassuring fetal heart rate.

A nurse is caring for a client whose last menstrual period (LMP) began July 8. Using Nagele's rule, the nurse should identify the client's estimated date of birth (EDB) as which of the following?

October 1

April 1

October 15

April 15

April 15

Using Nagele’s rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days

A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations?

Uteroplacental insufficiency

Fetal head compression

Fetal ventricular septal defect

Umbilical cord compression

Uteroplacental insufficiency

A late deceleration in the FHR is a nonreassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.

---

Fetal head compression causes early decelerations in the FHR.

A ventricular septal defect is an abnormal opening between the right and left ventricles of the fetus's heart. This defect does not cause late decelerations in the FHR during labor.

Compression of the umbilical cord causes variable decelerations in the FHR.

A nurse is teaching a client who is at 13 weeks of gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching?

"I am sad that I won't be able to get pregnant again."

"I can resume having sex as soon as I feel up to it."

"I should go to the hospital if I think I may be in labor."

"I should expect bright red bleeding while the cerclage is in place."

"I should go to the hospital if I think I may be in labor."

Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.

---

The client can expect spotting for 1 to 2 days after cerclage placement. However, the client should not have bright red bleeding while the cerclage is in place. The client should immediately go for evaluation if she experiences bright red bleeding.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take?

Perform a vaginal examination to determine cervical dilation.

Obtain blood samples for baseline laboratory values.

Place a spiral electrode on the fetal presenting part.

Prepare the client for a transvaginal ultrasound.

Obtain blood samples for baseline laboratory values.

---

A vaginal examination can lead to a hemorrhage if the client has placenta previa.

A spiral electrode can be placed only when the client’s membranes are ruptured, the cervix is sufficiently dilated, and placenta previa is ruled out because it can lead to hemorrhage.

The client should be on strict pelvic rest because she is experiencing bright red vaginal bleeding

A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hr. Which of the following actions should the nurse take?

Auscultate for a fetal heart rate.

Have the client drink orange juice.

Reassure the client that a term fetus is less active.

Palpate the uterus for fetal movement.

Auscultate for a fetal heart rate.

Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?

Blood pressure

Intake and output

Daily weight

Severity of edema

Daily weight

Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client’s fluid and electrolyte status.

A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?

Mild constipation

Nasal congestion

Vaginal bleeding

10 fetal movements per hour

Vaginal bleeding

Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.

---

The client should feel the fetus move at least 3 times per hour.

A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching?

"The fibroid will shrink during the pregnancy."

"The fibroid can increase the risk for postpartum hemorrhage."

"You will receive an injection of medroxyprogesterone acetate to shrink the fibroid."

"You will have to undergo a cesarean birth because of the fibroid."

"The fibroid can increase the risk for postpartum hemorrhage."

Uterine fibroids can increase the risk for postpartum hemorrhage due to the increase in blood supply to the uterus, which supports the fibroid.

---

The client will undergo serial ultrasound examinations during pregnancy to monitor the fibroid. The provider will not surgically remove the fibroid during pregnancy due to the risk for fetal injury or death and maternal hemorrhage.
The size and location of the fibroid will determine the safest method for delivery. If the client has a small fibroid that is not near the cervical os, she can have a vaginal delivery.

A nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate?

"You should drink 1 ounce of mineral oil every morning."

"You should walk for at least 30 minutes every day."

"You should eat at least 3 ounces of red meat per day."

"You should stop taking your prenatal vitamin."

"You should walk for at least 30 minutes every day."

The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following statements indicates to the nurse the client needs further instruction?

"I can continue to breastfeed."

"I will still need to have my provider perform a rubella titer check with my next pregnancy."

"I cannot receive the rubella immunization during my pregnancy."

"I can conceive any time I want after 10 days."

"I can conceive any time I want after 10 days."

A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.

---

A client should have a rubella titer check with each pregnancy to determine if she is still immune.

A client who is pregnant should not receive the rubella immunization because it is a live virus and can cause a rubella infection, which can cause miscarriage, congenital anomalies, or death of the fetus

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching?

"I must drink milk every day in order to assure good quality breast milk."

"Drinking lots of fluids will increase my breast milk production."

"After the first few weeks, my nipples will toughen up and breastfeeding won't hurt anymore."

"It is normal for my baby to sometimes feed every hour for several hours in a row."

"It is normal for my baby to sometimes feed every hour for several hours in a row."

Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8 to 12 times per day.

---

The newborn’s demand for milk will influence the mother’s milk production. As the newborn removes milk from the breast, the mother will produce more milk. Mothers who are breastfeeding should drink only to satisfy thirst.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration?

Continuous lochia flow and a flaccid uterus

Report of increasing pain and pressure in the perineal area

A slow trickle of bright vaginal bleeding and a firm fundus

A gush of rubra lochia when the nurse massages the uterus

A slow trickle of bright vaginal bleeding and a firm fundus

The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration.

---

The nurse should monitor for a report of increasing pain and pressure in the perineal area to identify a vulvar hematoma.

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse take first?

Perform a detailed physical assessment.

Place the newborn directly on the client's chest.

Give the newborn vitamin K IM.

Administer erythromycin ophthalmic ointment.

Place the newborn directly on the client's ch

The nurse should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client’s chest will help maintain the newborn’s temperature.

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification?

Monitor the client's intake and output.

Initiate a high-fiber diet for the client.

Monitor the client's weight weekly.

Initiate bedrest with the head of the bed elevated.

Monitor the client's weight weekly.

The nurse should weigh the client daily to monitor for fluid overload.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching?

"I will place my baby on his back when it is time for him to sleep."

"I will keep my baby's crib close to the heat vents to keep him warm."

"I will use an infant carrier when I drive to places close to my house."

"I will tie my baby's pacifier around his neck with a piece of yarn."

"I will place my baby on his back when it is time for him to sleep."

---

The parents should not place the newborn’s crib close to a heat source due to the risk of the crib linen catching on fire.

The parents should always place the newborn in an approved car seat whenever driving with the newborn. Infant carriers are not approved safety seats for motor vehicles.

The parent should never tie any type of string around the newborn’s neck due to the risk of strangulation.

A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client's temperature is 37.8° C (100° F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take?

Notify the provider about the elevated temperature.

Assist the client to empty her bladder.

Administer a bisacodyl suppository.

Massage the client's fundus.

Assist the client to empty her bladder.

When the client’s fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.

---

The nurse should not administer rectal suppositories and enemas to clients who have third- and fourth-degree lacerations due to the risk of injury to the suture line.

The nurse does not need to massage the client's fundus because it is firm and the gush of blood when ambulating is expected due to blood pooling in the vagina when the client is lying in bed.

Dehydration can cause a client who is postpartum to have a temperature up to 38° C (100.4° F) during the first 24 hr following delivery.

A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side?

Rooting

Moro

Tonic neck

Babinski

Tonic neck

• The tonic neck reflex (fencer position) occurs when the nurse quickly and gently turns the newborn’s head to one side.

• The newborn will extend the arm and leg on the same side while flexing the opposite arm and leg, resembling a fencing stance.

• This reflex disappears around 3-4 months of age.

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside?

Naloxone

Calcium gluconate

Protamine sulfate

Atropine

Calcium gluconate

The nurse should have calcium gluconate available to give to a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes.

A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?

Perform chest percussion.

Place the newborn in a prone position.

Continue routine monitoring.

Request a prescription for supplemental oxygen.

Continue routine monitoring.

• Newborns normally have irregular breathing patterns with periods of periodic breathing (short pauses in respiration lasting up to 10 seconds).

• A respiratory rate of 44/min is within the normal range (30-60 breaths/min) for a newborn.

• Shallow respirations with brief pauses (≤10 seconds) are expected in the first few hours of life as the newborn transitions to extrauterine breathing.

• No intervention is needed unless apnea lasts > 20 seconds, or is accompanied by cyanosis, bradycardia, or respiratory distress.

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions?

Terbutaline

Nifedipine

Magnesium sulfate

Methylergonovine

Methylergonovine

The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?

Offer the newborn glucose water between feedings.

Keep the newborn's eye patches on during feedings.

Apply barrier ointment to the newborn's perianal region.

Use a photometer to monitor the lamp's energy.

Use a photometer to monitor the lamp's energy.

• Phototherapy is used to treat newborn hyperbilirubinemia by breaking down bilirubin in the skin so it can be excreted in urine and stool.

• The lamp’s energy levels must be monitored using a photometer to ensure effective bilirubin breakdown without causing skin burns or retinal damage.

• Proper lamp intensity ensures safe and effective treatment while minimizing risks.

A nurse is providing teaching to the parents of a newborn about bottle feeding. Which of the following instructions should the nurse include in the teaching?

Dilute ready-to-feed formula if the newborn is gaining weight too quickly.

Prop the bottle with a blanket for the last feeding of the day.

Discard unused refrigerated formula after 72 hr.

Boil water for powdered formula for 1 to 2 min.

Boil water for powdered formula for 1 to 2 min.

The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination.

A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. Which of the following statements should the nurse make?

"You might have retained placental fragments in your uterus."

"Blood pools in the vagina when you are lying in bed."

"You might have a damaged blood vessel."

"The amount of blood flow will increase during the first few days after giving birth."

"Blood pools in the vagina when you are lying in bed."

In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia.

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.)

Magnesium sulfate infusion

Distended bladder

Oxytocin infusion

Prolonged labor

Small for gestational age newborn

Magnesium sulfate infusion is correct. Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus.

Distended bladder is correct. After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus.

Prolonged labor is correct. Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.

Small for gestational age newborn is incorrect. A large fetus and multifetal gestation can lead to over-stretching of the uterus and prevent uterine contractions.

Oxytocin infusion is incorrect. Oxytocin promotes uterine contractions.

A nurse is assessing a 4-hour-old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take?

Apply an oxygen hood over the newborn's head and neck.

Check the newborn's temperature using a temporal thermometer.

Place the naked newborn on the mother's bare chest and cover both with a blanket.

Give the newborn glucose water between feedings.

Place the naked newborn on the mother's bare chest and cover both with a blanket.

Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.

A nurse is caring for a newborn who is premature at 30 weeks of gestation. Which of the following findings should the nurse expect?

Abundant lanugo

Good flexion

Heel creases covering the bottom of feet

Dry, parchment-like skin

Abundant lanugo

Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development?

Rapidly advance oral feedings.

Position the naked newborn on the parent's bare chest.

Provide frequent periods of visual and auditory stimulation.

Discourage the use of pacifiers.

Position the naked newborn on the parent's bare chest.

Positioning the naked newborn on the parent’s bare chest can decrease stress in the parent and the newborn. This action can help maintain thermal stability, raise oxygen saturations, increase feeding strength, and promote breastfeeding.

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 to 2 hr of delivery?

Naloxone

Erythromycin ophthalmic ointment

Poractant alpha

Rotavirus immunization

Erythromycin ophthalmic ointment

Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth.

A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the following findings should the nurse expect?

Symmetric rib cage

Dry, wrinkled skin

Vernix over the entire body

Lanugo abundant on the back

Symmetric rib cage

A newborn who is born at 39 weeks of gestation is full-term and should have a symmetric rib cage.

---

A newborn who is born at 39 weeks of gestation is full-term and should have little to no vernix present at birth.

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect?

Legs that are shorter than the arms

Temperature of one leg differing from that of the other

Symmetrical gluteal folds

Limited abduction of one hip

Limited abduction of one hip

A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum.

A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take?

Assist the client to ambulate in the hallway.

Instruct the client to splint the incision with a pillow.

Have the client drink fluids through a straw.

Encourage the client to drink carbonated beverages.

Assist the client to ambulate in the hallway.

• Ambulation is the most effective way to relieve intestinal gas pain following a cesarean section.

• Movement stimulates peristalsis, helping the intestines expel trapped gas and prevent ileus (bowel obstruction).

• Gas pain is common postoperatively due to the slowed digestion and anesthesia effects during surgery.

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication?

Urinary output

Blood pressure

Fundal consistency

Pulse rate

Fundal consistency

Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, and blue hands and feet. Which of the following is the Apgar score the nurse should assign to the newborn?

7

8

9

10

9

A nurse is assessing a newborn 1 hr after birth. Which of the following assessment findings should the nurse report to the provider?

Jaundice of the sclera

Respiratory rate 50/min

Acrocyanosis

Blood glucose 60 mg/dL

Jaundice of the sclera

If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she inquires about the finding?

"This will resolve within 3 to 6 weeks without treatment."

"This will resolve on its own within 3 to 4 days."

"The provider might drain this area with a syringe."

"This is expected at birth so you don't need to worry about it."

"This will resolve within 3 to 6 weeks without treatment."

• The description (egg-shaped, edematous, bluish discoloration that does not cross the suture line) indicates a cephalohematoma.

• A cephalohematoma is caused by bleeding between the periosteum and the skull bone due to trauma during birth, often from forceps or vacuum-assisted delivery.

• Since the blood is trapped under the periosteum, it does not cross suture lines.

• The body gradually reabsorbs the blood, and the cephalohematoma resolves on its own within 3 to 6 weeks without treatment.