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WorksheetsMaternal Newborn Nursing Exam 2
Total questions: 115
Worksheet time: 2hrs 35mins
Certain risk factors have been identified as being associated with PPH. The RN should assess at-risk clients more often for PPH. Risk factors for PPH include which of the following ?(SELECT ALL THAT APPLY)
Multiple pregnancies
prolonged labor
macrosomia
microsomia
Identifying the cause of PPH is crucial to its successful treatment. The 4 T's acronym is used to remind nurses of the potential sources to consider. The 4 T's acronym include which of the following (select all that apply)
Tissue
Tone
Thrombin
Tearing
A client just gave birth. The placenta was examined and found to be intact. Fundal massage was completed. Upon reassessment the uterus was found to be boggy. Peripad saturated within 15 min. blood clots noted. what medical prescription does the nurse anticipate as an initial intervention in this situation?
Prepare for blood transfusion/ fluid bolus
prepare for surgical dilation and curettage
initiate intravenous magnesium sulfate
initiate intravenous oxytocin administration
Which of the following is included in the definition of PostPartum Hemorrhage?(select all that apply)
Blood loss greater than 500 mL during a vaginal birth
Blood loss of greater than 1000mL in a c-section
a greater than 5 point decrease in hematocrit from the admision level to postpartum period
a birth that results in the mother requiring a blood transfusion
The nurse is taking care of a 16 yr old client who is G1P0. when reading through prenatal records the nurse notes that the client has been very noncompliant with much of her prenatal care and instructions. The nurse is concerned that the client may be noncompliant with post delivery instructions and be at increased risk of PPH. Th nurse knows that PPH is the result of:
Uterine atony
poor nutrition
anemia during pregnancy
Preterm labor
The nurse is taking care of a postpartum client that has developed areas of brusiing on her arms and legs. She is concerned the client may be developing DIC. She knows that DIC can be triggered by: (SELECT ALL THAT APPLY)
preeclampsia
placental abruption
fetal demise
amniotic fluid embolism
preterm delivery
The nurse is caring for a postpartum clinet who has been experiencing excessive bleeding. The nurse midwife was notified. She came and examined the patient and placed one hand into the vagina and the other over the fundus to compress the uterus together in an attempt to control the bleeding. This technique is called:
Bimanual compression
Massaging the uterus
Balloon tamponade
Uterine stimulation
The nurse is caring for a post partum client that delivered 6 hours ago. she continues to have a large amount of lochia. The nurse knows that early PPH usually occurs within:
12 hours
24 hours
8 hours
36 hours
The nurse is assessing a postpartum client and her assessment findings indicate the client is experiencing PPH. What is the first action that the nurse needs to take?
massage the fundus
take vital signs
call for help
continue to monitor the situation
In the early stage of PPH, vital signs may be within normal limits and tolerated
True
False
The nurse is taking care of a post partum client and determines the uterus is soft and boggy. What action should the nurse take?
Massage the fundus to expel the blood
have the client get up and void
recheck the fundus in 15 min
have the infant breastfeed
The nurse is caring for a postpartum client that has experienced PPH. The nurse is teaching the client about nutrition. She knows that patients that have experienced this should consume a diet to help boost their blood levels therefore she will teach the cient to include which of the following foods in her diet?
Lean meat
Carbs
Vitamin C & D
Unsaturated fats
A nurse is teaching the postpartum client about nutrition. Which of the following will increase tissue healing in the postpartum client who has experienced significant tissue trauma and damage during delivery?
A
D
C
B
The nurse is caring for a postpartum client with uterine atony. She knows that uterine atony can be caused by (select all that apply)
Excessive distention and stretching of the uterine muscles from a large infant
Multiple pregnancies
Polyhydraminos
First time pregnancies
Microcephaly
The nurse is taking care of a postpartum client who she suspects subinvolution. The definition of subinvolution is:
A soft, boggy uterus
the inability of the fundus to decrease in size
a firm uterus
excessive bleeding from the uterus
The nurse is caring for a post partum client who is experiencing excessive bleeding. The nurse midwife was notified. The midwife placed a device into the uterus that she inflated with saline to compress the uterus. The name of this procedure is:
Bimanual compression
Balloon tamponade
uterine stimulation
massaging the uterus
The nurse is caring for a postpartum client in which there is a suspicion of retained placental tissue causing PPH. The nurse knows that which of the following actions is requred?
Manual exploration of the uterus and removal of tissue
The application of an automatic suction device to remove tissue
Massaging of the fundus to expell excess blood
IV fluids for hydration and removal of tissue
The nurse is caring for a postpartum client. The midwife is concerned the pt has developed a dangerous complication in which the placenta invades the deeper uterine layers of tissue. The nurse knows the nurse midwife is referring to which of the following conditions?
Placenta accreta
Placenta preveiw
Placenta atrphy
Placenta embedment
The nurse is caring for a postpartum client that recieved oxytocin during labor. Which of the following are considerations for oxytocin?(SELECT ALL THAT APPLY)
Discontinue with signs of water intoxication
Monitor BP during infusion
second line medication for PPH
Used for preeclampsia before delivery of the baby
Given for maternal hypotensino during labor
The nurse is caring for a group of postpartum clients. Which client would be most at risk for a postpartum hemorrhage?
THe client who has a temp of 99F just after delivery
The client who delivered twins by csection
the client who labored for 15 hours
the client who delivered a preterm infant at 34 weeks
When is the APGAR score of the Newborn obtained?
at 1 and 5 minutes
24 hours after delivery
15 and 30 min
1 hour and 12 hours
The nurse has just assessed the APGAR score of a newborn. When would the nurse reassess the infant if the score was 6 or less?
1 minute
5 minutes
10 minutes
30 minutes
A nurse is assessing the APGAR score of an newborn at one min. The score shows that the neonate is blue or pale with flexion of arms and legs; heart rate greater than 100, grimaces with suction, and has a weak cry. What is the APGAR score?
1
2
5
7
An apgar score of 0 to 3 indicates the need for:
full resusitation
some resusitation
routine post delivery care
An apgar score of 4 to 6 indicates the need for:
Full resusitation
some resusitation
routine post delivery care
An apgar score of 7 to 10 indicates the need for:
full resusitation
some resusitation
routine post delivery care
The nurse is assessing reflexes of the newborn. Which reflex is being assessed by stroking the cheek or edge of the newborns mouth resulting in the expected finding of the newborn turning its head toward the side that is touched and starts to suck?
Sucking and Rooting
Palmar Grasp
Plantar Grasp
Moro Reflex
A nurse is caring for a newborn who was born at 38 weeks gestation, weighs 3200g and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following?
Low birth weight
Normal for gestational age
small for gestational age
large for gestational age
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborns mouth. This finding is a characteristic of which of the following conditions?
Mongolian spots
Milia spots
Erythema toxium
Epstein's pearls
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following actions?
Hold the newborn vertically under arms and allow one foot to touch the table
Stimulate the pads of the newborns hands with stroking or massage
Stimulate the soles of the newborns feet on the outer lateral surface of each foot
hold the newborn in a semi-sitting postion, then allow the newborns head and trunk to fall backward
The nurse is completing an assessment on a newborn. Which of the following data indicate the newborn is adapting to extrauterine life? (SELECT ALL THAT APPLY)
expiratory grunting
inspiratory nasal flaring
Apnea for 10 second periods
Crackles and wheezing
obligatory nose breathing
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching about mongolian spots?
This is more commonly seen in newborns who have dark skin
This is a finding indicating hyperbilirubinemia
this is a forceps mark from an operative delivery
this is related to prolonged birth or trauma during delivery
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent opthalmia neonatorum. Which of the following medications should the nurse anticipate administering?
Ofloxacin
Nystatin
Erythromycin
Ceftriaxone
A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss?
Conduction
Convection
Evaporation
Radiation
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority?
Initiating breastfeeding
performing the intitial bath
Giving vitamin K injection
Covering the newborns head with a cap
A nurse is preparing to administer a vitamin K (phytonadione) injectino to a newborn. Which of the following responses should the nurse make when the parent asks why this medication is being given?
It assists with blood clotting
It is a preventative vaccine
it provides immunity
It promotes maturation of the bowel
A nurse is taking a newborn to a parent following a circumcision. which of the following actions should the nurse take for security purposes?
ask the parent to state their full name
look at the name on the newborns bassinet
match the parent's ID band with the newborns ID band
Compare the name on the bassinet and the room number
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse should provide which instruction to the mother?
feed the newborn less frequently
continue to breastfeed every 2-4 hours
switch to bottle feeding the infant for the next 2 weeks
stop breastfeeding and switch to bottle feeding permanently
Rooting Reflex
Newborns close their hands tightly when their palms are touched
Newborns extend their toes when the soles of their feet are touched
When newborns are touched on one of their cheeks, they turn their heads in that direction and open their mouths
When babies lie on their backs, they turn their heads to one side. If they turn to the right, their right hands go out, and their left arms go up.
When newborns are startled by a sudden movement, they spread their arms and legs apart and then bring them together again.
Palmer Grasp Reflex
Newborns close their hands tightly when their palms are touched
Newborns extend their toes when the soles of their feet are touched
When newborns are touched on one of their cheeks, they turn their heads in that direction and open their mouths
When babies lie on their backs, they turn their heads to one side. If they turn to the right, their right hands go out, and their left arms go up.
When newborns are startled by a sudden movement, they spread their arms and legs apart and then bring them together again.
Newborns generally feed about every _________________ hours.
4 - 5 hours
2 - 3 hours
3 - 5 hours
6 - 8 hours
Colostrum _______?
is produced by hormones
is early breastmilk
helps fight infections
all of the above
Jaundice is caused by:
A lack of vitamin K
Urinary Retention
Increased levels of unconjugated bilirubin
Shock in the newborn after birth
Treatment for Hyperbilirubinemia includes:
Flurotherapy- use of fluorescent light , provide additional fluids to prevent dehydration, monitor serum bilirubin.
Phototherapy- use of fluorescent light , provide no additional fluids to prevent dehydration, monitor serum bilirubin.
Phototherapy- use of fluorescent light , provide additional fluids to prevent dehydration, monitor serum bilirubin.
Psychotherapy- use of fluorescent light , provide additional fluids to prevent dehydration, monitor serum bilirubin.
All of these are safe sleep practices EXCEPT
Lying baby down on their back
Keeping the room temperature at 60 degrees or below
No soft objects in with baby that can impede breathing
Dressing baby in a sleeper that will keep them warm enough without a blanket
Putting baby down on a firm surface
when baby needs phototherapy for jaundice, (check all that apply)
make sure eyes are covered
mother should continue to breastfeed as often as possible
make sure you cover baby with warm blanket
change diaper every hour
place baby on it's abdomen
best treatment for diaper rash
keep baby's skin clean and dry as possible
clean with rubbing alcohol and air dry
apply baking soda and vinegar
clean with scented baby wipes
Cord care
leave open to air
clean with rubbing alcohol
cover it with the diaper
put vaseline around the site
how do you know baby has had enough to drink (check all that apply)
baby removes themself from the breast
baby seems satisfied
5-6 diapers per day (after 5 days)
baby cries often
skin is dry
Which is a normal newborn's vital sign
R-40/min,P-150/min, BP-60/50, T- 36.6
R-20/min, P-160/min, BP-100/60, T-36.8
R-45/min, P-150/min, BP-70/40, T-35.2
R-50/min, P-90/min, BP-70/40, T-38.0
A nurse should recognize which of the following as a manifestation of sepsis in the neonate? (Select all that apply)
lethargy
tachypnea
hypothermia
sunken fontanel
low serum glucose
While assessing a 29 y/o G2 P2 who had a normal Spontaneous vaginal delivery 30 minutes ago, the nurse notes a large amount of red vaginal bleeding. What would be the first priority nursing action.
check V/S
notify the HCP
firmly massage the uterine fundus
put the baby to breast
A 26 y/o G1 P1 who underwent a Cesarean 24 hours ago tells the nurse she is having trouble breast feeding. Which tasks can be appropriately delegated to the Unlicensed assistive personnel. Select all that apply.
providing the mother with an ordered abdominal binder
taking the mother's vital signs
checking the amount of lochia present
assisting the mother with ambulation
assisting the mother with breastfeeding
A full term newborn is in the clinic with his parents. he is 4 days old. His birth weight was 7lbs (3.2kg). Which assessment made by the nurse is the Most significant?
today's weight is 6 # 9 oz (3Kg)
the infants skin is peeling
the infants breast tissue is swollen
there is a yellow discharge from the infants right eye.
Methylergonovine is prescribed for a patient with postpartum hemorrhage. Before administering the medication, the nurse should contact the HCP if which condition is documented in the patients medical history?
hypotension
hypothyroidism
diabetes mellitus
peripheral vascular disease
The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?
Intradermal
Intratracheal
Subcutaneous
Intramuscular
A client in preterm labor (31) weeks who is dilated to 4 cms has been started on Magnesium Sulfate and the contractions have stopped. If the clients labor can be stopped for the next 48 hours, which medication can the nurse anticipate a prescription for?
Nulbuphine
Betamethasone
RH Immune globulin
Dinoprostone vaginal insert
The nurse in a newborn nursery is monitoring a preterm infant for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome. Select all that apply.
Cyanosis
Tachypnea
Hypotension
Retractions
Audible grunts
The nurse assisted with the birth of a newborn. which nursing action is the most effective in preventing heat loss by evaporation?
warming the crib pad
closing the doors to the room
drying the infant with a warm blanket
turning on the overhead radiant warmer
The nurse is assessing a newborn after circumcision and notes the circumcised area is red with a small amount of bloody drainage. Which nursing action is the most appropriate?
apply gently pressure
reinforce the dressing
document the findings
contact the HCP
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign is noted, would be an early sign of excessive blood loss?
a temperature of 100.4 (38 c)
an increase in pulse rate from 88 to 102 bpm
a blood pressure change from 130/88 to 124/80 mmHG
an increase in the respiratory rate from 18 to 22 breaths/min
The nurse is assessing the client in the fourth stage of labor and notes the fundus is firm, but that bleeding is excessive. Which should be the initial action?
document the findings
massage the fundus
notify the HCP
place the client in Trendelenburg
On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?
document the findings
elevate the clients legs
massage the fundus until its firm
push on the uterus to assist in expressing clots
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?
providing sitz baths
encouraging fluid intake
placing ice on the perineum
motioning H&H levels
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. the client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
client pain level
inadequate urinary output
client perception of body changes
potential for imbalanced body fluid volume
Tonic Neck Reflex
Newborns close their hands tightly when their palms are touched
Newborns extend their toes when the soles of their feet are touched
When newborns are touched on one of their cheeks, they turn their heads in that direction and open their mouths
When babies lie on their backs, they turn their heads to one side. If they turn to the right, their right hands go out, and their left arms go up.
When newborns are startled by a sudden movement, they spread their arms and legs apart and then bring them together again.
Feeding a baby when they are hungry, as opposed to every 2 hours is called....
none of the above
schedule
on demand
timing
Until your baby's umbilical falls off you should do what?
Only give sponge baths
Bathe the baby in 2 inches of water
Bathe the baby in a baby bath seat
Do not give the baby any form of a bath
Reflexes are controlled by what body system?
digestive
circulatory
nervous
cardiovascular
What is the normal period needed for a human baby to develop?
37 weeks
40 weeks
45 weeks
17 weeks
The soft spot on a baby's head is called ______
milia
fontanel
Which type of lochia should the nurse expect to find in a client 2 days PP?
Lochia delta
Lochia serosa
Lochia alba
Lochia rubra
A post-partum nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
On the day of the delivery
3 days PP
7 days PP
within 2 weeks PP
A new mother is breastfeeding her 2-day-old infant and tells the home health nurse that she can not believe her newborn wants to breastfeed again, since she just fed him 2 ½ hours ago. The nurse should plan to teach the client that a newborn usually should be nursed:
Hourly
On Demand
Every 4 hours
At 5-hour intervals
Needed to control the babies temperature
thermoregurigitation
positive feedback
warming
Thermoregulation
Milk thawed in the refridgerator can be stored for _____
6 hours
24 hours
2 days
One week
Weight is the most important the most important determinant of the percent of total body fluid loss in infants and younger children?
True
False
Secondary predictors of dehydration include all EXCEPT:
changing LOC
decreased skin elasticity and turgor
prolonged cap refill >2sec
absent crying
sunken eyes and fontanelles
Circumcision has been linked to which health benefits (select all that apply):
Prevention of UTI's in male infants younger than 1 year
Decreased risk of STI's (particularly HIV) in heterosexual intercourse
Increased hygiene
Reduced risk for penile cancer
Reduced risk for prostate cancer
Signs of hypoglycemia include: (Select all the apply)
Tremors
Hunger
Weak cry
Lethargy
Jaundice
Infants most at risk for cold stress are:
Large for gestational age
Premature
Macrosomic
Born in a hospital
The nurse checks the blood sugar of a 2-hour-old newborn and the glucometer reading is 32 mg/dL. The nurse should:
Recognize that this is a normal reading and document it.
Initiate breastfeeding.
Call the laboratory for a STAT blood glucose level.
Transfer the newborn to the NICU.
Respiratory Distress Syndrome (RDS) is caused by:
Lack of surfactant and immaturity of the lungs
Excessive surfactant and post-term delivery
Immaturity of the lungs due to use of insulin in diabetes
Excessive red blood cells due to chronic fetal hypoxia
A diabetic patient delivers her baby at 36 weeks gestation. The infant is jittery and lethargic. Which is the priority nursing action for this infant?
Applying oxygen
Obtaining a heel stick blood glucose
After drying, wrapping the infant in warm blankets
Putting the baby to the breast
Which intervention should the nurse include in the plan of care for a jaundiced newborn who is to receive phototherapy?
Keeping the baby fully clothed to avoid burns
Encouraging breastfeeding four to six
times per day
Placing eye protection on the baby during therapy
Reporting fewer than two stools per day to the provider
Which of the physical signs could indicate a risk for hyperbilirubinemia?
Acrocyanosis
Cephalohematoma
Newborn rash
Tremors
On days 9 of postpartum, the color of lochia is usually
dark red
yellowish
clear and watery
pinkish brown
Following the birth, the fundus
decreases about 1 cm/day for the first 9–10 days
decreases about 2 cm/day for the first 9–10 days
decreases about 3 cm/day for the first 9–10 days
increases the first two days and then decreases
Assessment of breastfeeding includes observing
attachment and effectiveness of suckling
effectiveness of suckling
position, attachment, and effectiveness of suckling
whether the mother has a sufficient supply of breast milk
The first step in the management of atonic uterus is
bimanual compression of the uterus
manual removal of the placenta
massage of uterus through the abdominal wall
compression of the abdominal aorta
What type of milk is present in the breasts 1-3 days PP?
mature milk
colostrum
transitional milk
pure milk
Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?
Cervical laceration
Perineal laceration
Clotting deficiency
Uterine subinvolution
Which of the following physiological responses is considered normal in the early postpartum period?
Urinary urgency and dysuria
Decrease in blood pressure
Increase motility of the GI system
Rapid diuresis
Causative agent can cause mastitis are
Candida albican
Staphylococcus aureus
E.coli
Bacteria vaginalis
Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
More than 200 ml
More than 300 ml
More than 400 ml
More than 500 ml
Which of the following are not the symptoms of postpartum blues?
hallucination
insomnia
loneliness
anxiety
4 T are causes of postpartum hemorrhage EXCEPT
tissue
tone
thrombin
target
