Maternal newborn practice test B with rationale | LATEST 2023/24 with complete solution

Maternal newborn practice test B with rationale | LATEST 2023/24 with complete solution A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? - *check for blood under the client's buttocks* The nurse should check for blood under the client's buttock to evaluate the amount of lochia flow and to check for pooling of blood that would otherwise be missed. A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have an immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times? - *prior to discharge from the hospital AFTER giving birth* The nurse should recommend the client receive the MMR vaccine following delivery, so she is protected from contracting rubella then and during any subsequent pregnancies. A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client? - *a large amount of bright red vaginal bleeding without pain* With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester. A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching? - *your baby can lose 5% of body weight during the first few days of life* The nurse should instruct the mother that the baby can have a weight loss between 5% and 10% of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight by their second or third week of life. A nurse in a provider's office is reinforcing teaching about home care with a client who has mild preeclampsia. Which of the following information should the nurse include in the teaching? - *perform daily fetal movements/kick counts* The client should count the number of fetal movements felt in one hour, preferably after a meal. Fetal movements are a reassuring sign of fetal oxygenation. The client should notify the provider if less than 3 movements per hour are noted, as this warrants further evaluation. A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority? - *dry the newborn* Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases oxygen demand and can result in respiratory distress and hypoglycemia. A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform? - *ask the client to empty her bladder* Whenever the fundus is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection. A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first? - *clear the respiratory tract* Using the airway, breathing, circulation (ABC) priority-setting framework, the first action the nurse should take is to open the airway of a newborn who was just delivered. A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect? - *pelvic pain* The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing pain as the tube stretches. A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse? - A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old Acrocyanosis in an infant who is 2-hr old *Jaundice in an infant who is 4-hr old* A hematocrit of 60% in an infant who is 8-hr old *Rationale* Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant? - *maintain integrity of the sac* The greatest risk to this client is injury from damage to the exposed spinal cord and fluid filled sac; therefore, the priority intervention is to maintain the integrity of the sac. A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse make? - *you must be feeling very scared* This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the cli