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CMS Maternal Newborn Practice 2020 A Questions and Correct Answers | Latest Update

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A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider? -:- Blurred vision - indication of preeclampsia Expected findings: non pitting ankle edema, 10 fetal movements in 2 ...

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  • September 19, 2024
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  • 2024/2025
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2024 /2025 | © copyright | This work may not be copied for profit gain Excel!




CMS Maternal Newborn Practice 2020 A
Questions and Correct Answers | Latest
Update
A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal

examination. Which of the following findings should the nurse report to the provider?


✓ -:- Blurred vision - indication of preeclampsia

✓ Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr,

leg cramps




A nurse is caring or a newborn who is receiving phototherapy. Which of the following

actions should the nurse take?


✓ -:- Place an opaque mask over the newborn's eyes - to prevent damage

to the retinas




- Should remove mask for feedings


DO NOT apply a thin layer of lotion to the newborn's skin




A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting.

Which of the following findings should the nurse identify as an indication that the client has

hyperemesis gravidarum?

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,2024 /2025 | © copyright | This work may not be copied for profit gain Excel!



✓ -:- Ketonuria




Occurs due to the breakdown of fat secondary to malnutrition or starvation


Tachycardia and tachypnea due to dehydration




A nurse is caring for a newborn who has a high-pitched cry and does not respond to

consoling efforts. Which of the following neonatal data collection tools should the nurse

expect to complete?


✓ -:- Neonatal Abstinence Scoring System: exhibiting opioid withdrawal




Additional manifestations: restlessness, tremors, increased muscle tone, and an exaggerated

Moro reflex


- Apgar score: heart rate, respiratory rate, muscle tone, reflex irritability and skin color


- Newborn Hearing Screen should be completed before the newborn is discharged from the

hospital


- Critical Congenital Heart Disease screen should be completed 24- 28 hours following

birth and before the newborn is discharged from the hospital




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,2024 /2025 | © copyright | This work may not be copied for profit gain Excel!



A nurse is assisting in the care of a newborn immediately following birth. Which of the

following images should the nurse identify as an indication that the newborn has a

myelomeningocele?


✓ -:- Occurs when the neural tube fails to close, and the meninges and

spinal cord herniate

Occurs in the lumbar area and may be covered by a thin membranous sac


- Exstrophy of the bladder; occurs from abnormal development of the abdominal wall,

symphysis pubis and bladder ; visible in the suprapubic area and requires surgical

intervention soon after birth


- Omphalocel: occurs when abdominal organs herniate through the umbilical ring at the base

of the umbilical cord


- Cephalohematoma; collection of blood between the skull bone and its covering, the

periosteum. A cephalohematoma does not cross the suture lines of the newborn's skull and

will spontaneously resolve in 2-8 weeks




A nurse is collecting data from a newborn who is 8hr old. Which of the following findings

should the nurse report to the provider?


✓ -:- Apical heart rate of 90/min while crying - normal range 110 - 160 for

a newborn, heart rate of 80-100/min while asleep and up to 180/min

while crying


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, 2024 /2025 | © copyright | This work may not be copied for profit gain Excel!



- Apneic episode of 20 seconds or less - normal; newborns respirations are normally

shallow and irregular


- Positive moro reflex present from birth up to 8 weeks


- Vernix in the skin folds - normal




A nurse 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?


a. administer analgesics


b. apply an ice pack to the perineum


c. assist the client with breastfeeding


d. help the client ambulate to the toilet


✓ -:- d. help the client ambulate to the toilet




The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore,

the priority intervention by the nurse is to assist the client to urinate and completely empty

the bladder, which will allow the uterus to contract.




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