PN Maternal Newborn Practice Assessment
2020 A with NGN
A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium
sulfate via continuous IV infusion. Which of the following statements should the nurse include in
the teaching?
- "We will monitor your blood pressure every 2 hours"
- "Your fluid intake will be limited to no more than 125 milliliters per hour"
- "You might notice that you will begin breathing faster than normal"
- "We will monitor your baby's heart rate once per hour" - ANSWER - "Your
fluid intake will be limited to no more than 125 milliliters per hour"
A nurse is caring for a client who is at 20 weeks gestation and is in the clinic for a routine
prenatal visit. Which of the following findings in the data form the client's medical record should
the nurse report to the provider? (click on exhibit tabs)
Exhibit 1:
BP Week 16: 120/70 mm Hg Week 20: 130/80 mm Hg
Weight Week 16: 61.7 kg (136 lb) Week 20: 63 kg (138.9 lb)
Exhibit 2:
Fundal Height Week 16: 16 cm Week 20: 25 cm
Fetal Heart Rate Week 16: 156/min Week 20: 160/min
Exhibit 3:
Diagnostic results urine negative for albumin and glucose both wks
A nurse who is caring for a client 6 hr after a vaginal birth who is going to breastfeed her
newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild
perineal edema and ecchymosis with a fundus that is 2 cm above the umbilicus with deviation
to the right. Which of the following actions is the nurse's priority?
- Administer analgesics
- Apply an ice pack to the perineum
- Assist the client with breastfeeding
- Help the client ambulate to the toilet - ANSWER - Help the client ambulate to
the toilet
A nurse is assisting with the care of a client who is postpartum and is receiving magnesium
sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should
the nurse identify as manifestations of magnesium toxicity? (select all that apply)
A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following
findings should the nurse identify as an indication of a potential complication of pregnancy?
- Leg cramps
- Tingling of fingers
- Varicose veins
- Epigastric pain - ANSWER - Epigastric pain
A nurse is reinforcing planning options with a client who is requesting information about
contraceptives. Which of the following client statements indicates an understanding of the
teaching?
- "The diaphragm should be removed 2 hours after having intercourse"
- "I can use water-soluble lubricant when my partner wears a latex condom"
- "It is okay for me to remove the birth control sponge within 2 hours after having intercourse"
- "When I use the birth control patch, it must be changed once a month" - ANSWER
- "I can use water-soluble lubricant when my partner wears a latex condom"
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