A woman who have birth 2 hours ago has a temperature of 37.9 *C. Select all of the immediate nursing actions
A) Have pt drink 2 glasses of fluid over the next hour
B) Explain to the patient that she needs to rest and assist her into a comfortable position
C) Medicate pt with 500 mg of acetamin...
Maternity Exam 1 Practice Questions &
Answers
A woman who have birth 2 hours ago has a temperature of 37.9 *C. Select all of the
immediate nursing actions
A) Have pt drink 2 glasses of fluid over the next hour
B) Explain to the patient that she needs to rest and assist her into a comfortable position
C) Medicate pt with 500 mg of acetaminophen as per orders
D) Call the patient's physician or midwife to report the elevated temp - ANSWERSA & B
Reasoning:
A mild temperature elevation within a few hours of birth can be related to dehydration
and exhaustion. Acetaminophen is given if temperature remains elevated after the
woman has been hydrated and rested. The physician or midwife is notified if
temperature remains elevated after initial interventions.
3 hours after a vaginal delivery, the client complains of increased perineal pain. What
should the nurse do first?
A) Administer analgesia as ordered
B) Assess the perineum
C) Perform perineal care
D) Apply ice to perineum - ANSWERSB
A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40
weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of
Vitamin K, the nurse will:
A) Explain to the parents the action of the medication and answer their questions
B) Remove neonate from the room so parents will not be distressed by seeing the
injection
C) Completely undress the neonate to identify the injection site
D) Replace needle with a 21 gauge ⅝ needle - ANSWERSA
Reasoning: It is important to always explain to parents wHat and why a procedure is
being done on the newborn
When assessing a placenta and umbilical cord at delivery, the nurse must know that the
normal cord has:
A) 1 vein and 2 arteries
B) 2 veins and 1 artery
C) 1 vein and 1 artery
,D) 2 veins and 2 arteries - ANSWERSA
(AVA)
When reviewing a potential cause for postpartum hemorrhage with the student nurse,
the nurse is sure to include the finding of a(n) ____________ bladder -
ANSWERSFULL/OVERDISTENDED
Reasoning:
An overdistended bladder, which displaces the uterus above and to the right of the
umbilicus, can cause uterine atony and lead to hemorrhage
Maddy, a G3 P1 woman, gave birth 12 hrs ago to a 9lb 13 oz daughter. She
experiences severe cramps with breastfeeding. The perinatal nurse best describes this
condition as:
A) Afterpains
B) Uterine hypertonia
C) Bladder hypertonia
D) Rectus abdominis diastasis - ANSWERSA
Reasoning
Afterpains are intermittent uterine contractions that occur during the process of
involution. Afterpains are more pronounced in patients w/ decreased uterine tone due to
overdistension, which is associated w/ multiparity and macrosomia. Patients often
describe the sensation as a discomfort similar to menstrual cramps
What does GTPAL mean? - ANSWERSG: Gravida → # of times a woman has
conceived including current pregnancy
T: Term Births → # of times a woman has carried a pregnancy to at least 37 weeks and
delivered
P: Preterm Births → # of births a woman has delivered before 37 weeks gestation but
after 20 weeks
A: Abortions → # of times a woman has lost a pregnancy, whether it was elective or
spontaneous (miscarriage), before 20 weeks gestation
L: living children → live births
The best way for the nurse to enhance parental confidence is to
A) Have the parents watch a video tape of infant care, then discuss it with them
B) Demonstrate skills on the newborn while providing care
C) Encourage new parents to ask their friends about infant care
D) Provide encouragement and positive feedback - ANSWERSD
,The nurse is teaching the parents of a female baby how to change a baby's diapers.
Which of the following should be included in the teaching?
A) Always wipe the perineum from front to back
B) Remove any vernix caseosa from labia folds
C) Put powder on buttocks every time the baby stools
D) Weigh every diaper in order to assess for hydration - ANSWERSA
Reasoning
To decrease risk of infection from bacteria from the rectum, the perineum of female
babies should always be cleansed from front to back
After birth, the perinatal nurse explains to the new mom that Progesterone is the
hormone responsible for stimulating milk production
A) True
B) False - ANSWERSFALSE
A 6 hour infant passes an unformed, black, tar like stool. The nurse should conclude
this is a:
A) Meconium stool expected at the time of birth
B) Transitional stool expected at this time
C) Meconium stool expected at this time
D) Transitional stool expected later - ANSWERSC
A woman's postpartum vaginal discharge is dark red and contains shreds of decidua
and epithelial cells. The nurse should describe the discharge in the nurse's notes as:
A) Rubra
B) Serosa
C) Alba
D) Erythra - ANSWERSA
Which of the following statements indicates that a new mom needs additional teaching?
A) I will need to supervise my cat when she is in the same room as my baby
B) I will place by baby on her back when she is sleeping
C) I will not leave my baby on an elevated flat surface after she is able to turn over on
her own
D) I have asked my husband to install safety latches on the lower cabinets -
ANSWERSC
Reasoning:
Newborns/infants should never be left on an elevated flat surface because they may roll
or wiggle & fall off
The perinatal nurse explains to the student nurse that the growing embryo is called a
___________ at the end of 8 weeks of gestational age
A) Neonate
B) Fetus
, C) Zygote
D) Gamete - ANSWERSB
Reasoning
- Zygote = fertilization - 2nd week
- Embryo = end of 2nd week - 8th week
- Fetus = end of 8th week - birth
A mother refused to allow her son to receive the vitamin K injection at birth. Which of
the following s/s might the nurse observe in the baby as a result?
A) Skin color is dusky
B) Vitals signs are labile
C) Glucose levels are subnormal
D) Circumcision site oozes blood - ANSWERSD
Reasoning
The circumcision site may ooze blood due to lack of Vitamin K, which is required for the
hepatic synthesis of blood coagulation factors II, VII, and X
The nurse is assessing a client 24 hrs after delivery and finds the fundus to be slightly
boggy and 2 centimeters above the umbilicus. What should the nursing priority
intervention be?
A) Document this expected finding
B) Notify the physician
C) Gently massage the fundus until firm
D) Assess mom's vital signs - ANSWERSC
During a postpartum assessment, the nurse notes that the uterus is midline and boggy.
The immediate nursing action is:
A) To notify the patient's midwife or physician
B) Massage the fundus until firm and reevaluate within 30 minutes
C) Give syntocinon as per orders
D) Assist the patient to the bathroom and ask her to void - ANSWERSB
Reasoning
The first nursing action for a boggy uterus = massage the fundus
A perinatal nurse assesses the skin condition of a newborn, which is characterized by a
yellow coloration of the skin, sclera, and oral mucous membranes. What condition is
most likely the cause of this symptom?
A) Hypoglycemia
B) Physiologic anemia of infancy
C) Low glomerular filtration rate
D) Jaundice - ANSWERSD
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