CMS Maternal Newborn Proctored 2019 Flashcards
- A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection?
a. Unilateral breast pain
b. Persistent abdominal striae
c. Lochia alba
d. WBC count 12,000/mm3
ANS: A
a. Unilateral breast pain
i. Mastitis - painful or tender localized hard mass and reddened area, usually on one breast. (Pg. 143)
b. Persistent abdominal striae
i. Stretch marks - expected finding
c. Lochia alba
i. Lasts approx day 11 up to 4-8 weeks post-birth
d. WBC count 12,000/mm3
- A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?
a. blood glucose 110 mg/dL
b. Deep tendon reflexes of 2+
c. Urine protein 3+
d. Hemoglobin 13 g/dL
ANS: C - Urine protein 3+
i. Severe preeclampsia: consists of blood pressure that is 160/110 mmHg or greater, proteinuria greater than 3+, oliguria, elevated serum creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia.
- A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?
a. “This medication improves tissue perfusion.”
b. “This medication increases cardiac output.”
c. “This medication stabilizes the fetal heart rate.”
d. “This medication prevents seizures.”
ANS: D - “This medication prevents seizures.”
i. Depresses CNS. (Pg 61) ATI Maternal Newborn 2
- A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? (pg 76)
a. “You will have dilation and effacement of the cervix.”
b. “Your contractions will become temporarily regular.”
c. “You will have bloody show.”
d. “Your contractions will become more intense when walking.”
ANS: B - “Your contractions will become temporarily regular”
A, C, D = All signs of TRUE labor
- A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy?
a. Check the newborn’s identification using the crib card.
b. Replace the infant’s identification band after his name has been recorded.
c. Require visitors to wear an identification band.
d. Obtain an imprint of the infant’s feet prior to taking him to the nursery.
ANS: D - Obtain an imprint of the infant’s feet prior to taking him to the nursery
- A nurse is caring for a client who delivered by cesarean birth 6 hrs. ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
a. Apply an ice pack to the incision site.
b. Replace the surgical dressing.
c. Administer 500 mL lactated Ringer’s IV bolus.
d. Evaluate urinary output.
ANS: D - Evaluate urinary output
i. Encourage the client to empty her bladder frequently (every 2 to 3 hr) to prevent possible displacement of the uterus and atony.
ii. Frequent voiding of less than 150 mL of urine is indicative of urinary retention with overflow.
Administer 500mL LR IV Bolus is for hydration
- A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching?
a. Use breast binder for 2 days
b. Wear nipple shields during the feeding
c. Use plastic-lined breast pads.
d. Apply cabbage leaves after feedings
ANS: D - Apply cabbage leaves after feedings
- A nurse is calculating the estimated date of birth using Nagele’s rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year?
a. March 14
b. March 21
c. March 28
d. April 4
ANS: C - March 28
Naegele’s rule: Subtract 3 months from LMP
Add 7 days
- A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
a. Inform the client that the law requires her to name the fetus.
b. Limit the amount of time the fetus is in the client’s room
c. Instruct the client that an autopsy should be performed within 24 hrs.
d. Prepare the client for what to expect the fetus to look like.
ANS: D - Prepare the client for what to expect the fetus to look like.
- A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client’s arms, the mother states, “No, the baby is too tired to be held.” Which of the following actions should the nurse take?
a. Demonstrate how to hold the newborn and allow client to practice.
b. Persuade the client to breastfeed the newborn to promote bonding.
c. Offer to take the newborn to the nursery to finish his feeding.
d. Insist that the mother pick up the newborn to feed him.
ANS: A - Demonstrate how to hold the newborn and allow client to practice.
- A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?
a. Intense contractions lasting 45 to 60 seconds
b. An urge to have a bowel movement during contractions
c. A sense of excitement and warm, flushed skin
d. Progressive sacral discomfort during contractions
Answer
Either B or C
