PQ-300T: Maternal Newborn P2

Question 1

A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

a. “I will wear a snug fitting bra.”
b. “I will apply ice packs to my breasts.”
c. “I should stimulate my nipples by squeezing softly.”
d. “I should crush cabbage leaves and place them on my breast.”

Answer 1

c. “I should stimulate my nipples by squeezing softly.”

​Nipple stimulation should be avoided during breast engorgement. Nipple stimulation causes milk production and can exacerbate the engorgement. Breast engorgement is characterized by painful overfilling of the breasts. Cold compresses, raw cabbage leaves, a snug-fitting bra, and analgesics can be used to relieve the swelling and pain.

Question 2

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby’s mouth, which of the following responses by the nurse is appropriate?

a. “You should place your nipple and some of the areola into her mouth.”
b. “Babies know instinctively exactly how much of the nipple to take into their mouth.”
c. “Your baby’s mouth is rather small so she will only take part of the nipple.”
d. “Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth.”

Answer 2

a. “You should place your nipple and some of the areola into her mouth.”

​Placing the nipple and part of the areola into the baby’s mouth will aid in adequately compressing the milk ducts. This placement also decreases stress on the nipple and helps prevent cracking and soreness.

Question 3

A nurse is assisting in the care of a newborn immediately after birth. At 5 min after birth, the newborn has acrocyanosis, flexed extremities, a grimace when suctioned, a heart rate of 130/min, and a lusty cry with tactile stimulation. What should the nurse document as the newborn’s 5-min Apgar score?

Answer 3

8

The nurse should document the newborn’s 5-min Apgar score as an 8. Apgar scoring is an assessment of the newborn’s transition to extrauterine life and includes five areas: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and respiratory effort. The grimace when suctioned and acrocyanosis score 1 each for reflex irritability and color, which is an overall score of 8.

Question 4

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

a. Ask another nurse to verify the heart rate.
b. Document this as an expected finding.
c. Call the neonatologist to assess the newborn.
d. ​Prepare the newborn for transport to the NICU.

Answer 4

b. Document this as an expected finding.

The expected reference range for apical pulse in a newborn is 120 to 160/min. The nurse should document this as an expected finding.

Question 5

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

a. Abruptio placentae
​b. Placenta previa
​c. Preterm labor
​d. Threatened abortion

Answer 5

​b. Placenta previa

Painless, bright red vaginal bleeding is a manifestation of placenta previa.

Question 6

A nurse is caring for a client in the immediate postoperative period following removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) immune globulin?

a. The client is Rh-negative.
b. The client has previously given birth to an Rh-negative infant.
c. The client has expressed a desire to conceive again.
d. The client has had significant blood loss during the procedure.

Answer 6

a. The client is Rh-negative.

Administering Rho(d) immune globulin to the client prevents the formation of antibodies to Rh-positive blood. Exposure can occur following delivery, spontaneous or induced abortion, or amniocentesis involving an Rh-positive fetus.

Question 7

A nurse is reinforcing teaching with a group of clients about nutritional requirements during lactation. Which of the following nutrients should the nurse instruct the clients to increase?

a. Sodium
​b. Zinc
​c. Folic acid
​d. Iron

Answer 7

​b. Zinc

The nurse should recommend an increased intake of zinc to support lactation.

Question 8

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

a. Obtain a prescription for an antibiotic.
b. Express milk from both breasts.
c. Apply a heating pad to her breasts.
d. Wear a nipple shield.

Answer 8

b. Express milk from both breasts.

​For this postpartum day, the client’s fundal location and lochia characteristics are within the expected reference range. The client’s manifestations indicate that she is experiencing breast engorgement, an expected finding, as this is the time when the milk “comes in.” Frequent breastfeeding and expressing milk from the breasts can help relieve engorgement.

Question 9

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

a. Two-vessel umbilical cord
b. Precipitous birth
c. Small for gestational age newborn
d. Gestational hypertension

Answer 9

b. Precipitous birth

A client who has a precipitous birth is at an increased risk for postpartum hemorrhage.

Question 10

A nurse is assisting in the care of a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?

a. Instruct the client to apply mineral oil to the nipples after each feeding.
b. Encourage the client to keep the nipples covered when not breastfeeding.
c. Instruct the client to limit feedings to 10 min on each breast.
d. Encourage the client to change the newborn’s position with each feeding.

Answer 10

d. Encourage the client to change the newborn’s position with each feeding.

​The nurse should encourage the client to reposition the newborn for each feeding to decrease nipple soreness. The client should also ensure the newborn’s mouth is wide open prior to latching on to the breast.

Question 11

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?

a. Assist the client to ambulate.
b. Perform fundal massage.
c. Increase the rate of the IV fluids.
d. Check for blood under the client’s buttock.

Answer 11

d. Check for blood under the client’s buttock.

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.

Question 12

A nurse is reinforcing teaching about newborn care with a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

a. “I should keep my baby’s head covered.”
b. “My baby’s temperature will be checked rectally every hour.”
c. “I will place my baby on my stomach and cover her with a warm blanket.”
d. “My baby’s bassinet should be kept away from fans and air conditioning.”

Answer 12

b. “My baby’s temperature will be checked rectally every hour.”

The newborn’s axillary temperature should be checked every hour until the newborn’s temperature stabilizes. Frequent rectal temperature checks are not recommended and can lead to rectal mucosal injury.

Question 13

A nurse is collecting data from a newborn who is 12 hr old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

a. Activate respiratory arrest procedures.
b. Report the observation to the charge nurse immediately.
c. Continue routine monitoring.
d. Request an order for supplemental oxygen.

Answer 13

c. Continue routine monitoring.

This observation indicates adaptation of the respiratory system to extrauterine life. Continued monitoring is indicated.

Question 14

A nurse is collecting data from a newborn who is 48-hr old. Which of the following findings should the nurse report to the provider?

a. Telangiectatic nevi
b. Erythema toxicum
c. Generalized petechiae
d. Mongolian spot

Answer 14

c. Generalized petechiae

Generalized petechiae can indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation.

Question 15

A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority?

a. Platelets 200,000/mm³
b. Bilirubin 18 mg/dL
c. Blood glucose 50 mg/dL
d. Hemoglobin 22 g/dL

Answer 15

b. Bilirubin 18 mg/dL

Bilirubin 18 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age. Therefore, the nurse should identify this as the priority finding.

Question 16

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings requires immediate intervention by the nurse?

​a. Decreased urge to void
​b. Increased urine output
​c. Displaced fundus from the midline
​d. Fundal height below the umbilicus

Answer 16

​c. Displaced fundus from the midline

​Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage. A distended bladder can cause uterine atony and lateral displacement from the midline of the lower abdomen, usually to the right. This occurs because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. This finding requires immediate intervention by the nurse.

Question 17

A nurse is caring for a newborn who is formula fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client’s intake for the shift?

Answer 17

90 mL

Add the total ounces: 0.5 + 1 + 0.5 + 0.5 + 0.5 = 3 oz. Then multiply the total ounces by 30 mL: 3 x 30 = 90 mL

Question 18

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad. Which of the following actions should the nurse take first?

a. Request the provider perform a vaginal examination.
b. Feel for a full bladder.
c. Measure the client’s vital signs.
d. Check the client’s fundus.

Answer 18

d. Check the client’s fundus.

The primary cause of excessive postpartum bleeding is uterine atony. The priority action the nurse should take is to check the client’s fundus. A boggy fundus requires massage by the nurse. Failure of the uterus to contract with massage warrants further intervention by the nurse, such as having the client empty her bladder.

Question 19

A nurse is reinforcing teaching with a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse recognizes that which of the following is the most common risk factor for a placental abruption?

a. Maternal cocaine use
b. ​Maternal hypertension
​c. Maternal battering
​d. Maternal cigarette smoking

Answer 19

b. ​Maternal hypertension

​Maternal hypertension is the most common risk factor for placental abruption.

Question 20

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

​​a. Obtain blood glucose by heel stick.
​b. Initiate phototherapy.
c. ​Measure the newborn’s blood pressure.
​d. Place the newborn in a radiant warmer.

Answer 20

​​a. Obtain blood glucose by heel stick.

​The newborn is exhibiting early signs of hypoglycemia. Other signs of hypoglycemia include poor feeding, tremors, hypothermia, flaccid muscle tone, irregular respirations, apnea, cyanosis, and a weak, shrill cry. The nurse should obtain blood by heel stick to check glucose levels. A therapeutic serum glucose level for a newborn is 40 to 60 mg/dL. Less than 35 mg/dL indicates hypoglycemia. The newborn can be treated with frequent oral or gavage feedings, or continuous parenteral nutrition. Early breastfeeding also should be encouraged to prevent hypoglycemia. Untreated hypoglycemia can lead to seizures, brain damage, and death.

Question 21

A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?

​a. Moist skin
b. Protruding abdomen
​c. Gray umbilical cord
d. ​Wide skull sutures

Answer 21

d. ​Wide skull sutures

Newborns who are small for gestational age have wide skull sutures due to inadequate bone growth.

Question 22

A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression. Which of the following instructions should the nurse include?

a. Contact a crisis counselor once a week.
b. Stay home until one week after delivery.
c. Sleep as much as possible.
d. Return to work two weeks after delivery.

Answer 22

c. Sleep as much as possible.

The nurse should encourage the client to sleep as much as she can during the next few weeks. Sleep deprivation can increase the risk for postpartum depression.

Question 23

A client is concerned that her newborn has “crossed eyes.” Which of the following statements is a therapeutic response by the nurse?

a. “Newborns lack the necessary muscle control to regulate eye movement.”
b. “I’ll take your baby back to the nursery for an examination.”
c. “I will call your provider and report your concerns.”
d. “This condition is easily treated by patching your baby’s eyes.”

Answer 23

a. “Newborns lack the necessary muscle control to regulate eye movement.”

Transient strabismus or nystagmus are common until the third or fourth month of life; therefore, the nurse should reassure the client that this is an expected finding.

Question 24

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?

a. Dry the newborn.
b. Administer phytonadione IM.
c. Document the Apgar score.
d. Apply identification bands.

Answer 24

a. 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.

Question 25

A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis?

​a. Swelling in both breasts
​b. Cracked and bleeding nipples
​c. Red and painful area in one breast
d. Increase in breast milk

Answer 25

​c. Red and painful area in one breast

​Mastitis often appears as a red, hard, and painful area. Although mastitis can occur in both breasts, it is usually unilateral. After delivery, the nurse should monitor the client’s breasts for signs of mastitis and reinforce instruction about breast self-examination.

Question 26

A nurse is reinforcing about Rho(D) immunoglobulin to a client who is pregnant. Which of the following findings can an Rh incompatibility cause?

a. Hydrops fetalis
​b. Hypobilirubinemia
​c. Congenital hypothermia
​d. Transient clotting difficulties

Answer 26

a. Hydrops fetalis

Hydrops fetalis is a serious condition that occurs when fluid builds up in multiple body parts of the fetus and is a result of an Rh incompatibility.

Question 27

A nurse is caring for a client who is pregnant and reports constipation. Which of the following recommendations should the nurse make?

a. Regular use of a laxative
b. Maintenance of good posture
c. Increased cellulose and fluid in the diet
d. Regular use of glycerine suppositories

Answer 27

c. Increased cellulose and fluid in the diet

Increasing fiber and fluid and getting regular exercise are simple and effective ways to deal with constipation during pregnancy.

Question 28

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

a. Apply an ice pack to the perineum.
b. Prepare a warm sitz bath.
c. Place a soft pillow under the client’s buttocks.
d. Position a heating lamp toward the episiotomy.

Answer 28

a. Apply an ice pack to the perineum.

During the first 24 hr, ice packs and cool water sitz baths should be used. This should reduce edema and reduce discomfort. The client can also apply witch hazel compresses to reduce edema. The nurse should also teach the client to use prescribed creams, sprays, and ointments.

Question 29

A nurse is collecting data from a client who is 3 hr postpartum. The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse take?

a. Massage the fundus.
b. Insert a urinary catheter.
​c. Have the client urinate.
​d. Administer analgesia.

Answer 29

c. Have the client urinate.

A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. Having the client urinate allows the uterus to settle back to midline below the umbilicus.

Question 30

A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. What should the nurse document as the newborn’s 1-min Apgar score?

Answer 30

6

The nurse should document the newborn as having a 1-min Apgar score of 6. Apgar scores are based on five signs that are evaluated in a newborn at 1 and 5 min after birth that reflect the newborn’s transition to extrauterine life. The five signs are assigned a score of 0, 1, or 2, depending on the nurse’s findings. The five signs and their associated scoring for this newborn at 1 min after birth are: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1.