CMS Maternal Newborn Practice 2020 A Questions & Answers
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Course
CMS Maternal Newborn
Institution
CMS Maternal Newborn
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? - ANSWERSBlurred vision - indication of preeclampsia
Expected findings: non pitting ankle edema, 10 fetal movements in 2 ...
CMS Maternal Newborn Practice 2020 A
Questions & Answers
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? -
ANSWERSBlurred 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? - ANSWERSPlace 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? - ANSWERSKetonuria
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? - ANSWERSNeonatal 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
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? - ANSWERSOccurs 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? - ANSWERSApical 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
- 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 - ANSWERSd. 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.
A nurse is reinforcing teaching with a client who is at 20 wks of gestation and has
gestational diabetes mellitus. Which of the following information should the nurse
include in the teaching?
a. exercise before meals
b. consume at least 2,000 cal/day
c. avoid consuming an evening snack
d. maintain a fasting blood glucose of 110 to 120 mg/dL - ANSWERSb. consume at
least 2,000 cal/day
This will ensure adequate glucose intake and prevent hypoglycemia. Exercise should be
done after meals to prevent hypoglycemia. Should have an evening snack to prevent
hypoglycemia during the night. Should maintain a fasting blood glucose of less than 95
mg/dL.
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