PQ-300T: Maternal Newborn P3

Question 1

A nurse is caring for a client who is pregnant. The client states that they are not sure that their health plan will cover the pregnancy. Which of the following statements should the nurse make?

a. “The American with Disabilities Act ensures that your pregnancy will be covered under your health insurance plan.”
b. “You should switch to another plan that will cover your pregnancy.”
c. “The Affordable Care Act includes maternity and newborn care. Therefore, your pregnancy is covered under your health insurance plan.”
d. “You should find a provider who is covered by your health insurance plan.”

Answer 1

c. “The Affordable Care Act includes maternity and newborn care. Therefore, your pregnancy is covered under your health insurance plan.”

Maternity and newborn care are essential benefits included in the Affordable Care Act (ACA).

Question 2

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

a. Oligohydramnios
b. Small for gestational age newborn
c. Newborn hypoglycemia
d. Placenta previa

Answer 2

c. Newborn hypoglycemia

The nurse should identify that hypoglycemia is a common complication for newborns whose mothers have gestational diabetes.

Question 3

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.)

a. Cracked, peeling skin
b. Moro reflex
c. Abundant lanugo
d. Vernix in the folds and creases
e. Heel to ear maneuverability

Answer 3

a. Cracked, peeling skin
b. Moro reflex

Cracked, peeling skin is correct. A post-term newborn, born after 42 weeks of gestation, typically has cracked, peeling skin.
Moro reflex is correct. Reflexes do not change with postmaturity. An intact Moro reflex is an expected finding.
Abundant lanugo is incorrect. Abundant lanugo is a manifestation of prematurity, not postmaturity.
Vernix in the folds and creases is incorrect. The absence of vernix is characteristic of postmaturity.
Heel to ear maneuverability is incorrect. The ability to maneuver the infant’s heel to his ear is characteristic of prematurity, not postmaturity.

Question 4

A nurse is reinforcing teaching about reliable sources of Vitamin B12 with a client who is pregnant. Which of the following foods should the nurse recommend in the teaching?

a. Figs
b. Broccoli
c. Stewed tomatoes
d. Skim milk

Answer 4

d. Skim milk

The nurse should recommend skim milk as reliable source of vitamin B12, because eight ounces of milk has 0.93 mcg of vitamin B12 and the client’s daily requirement is 2.4 mcg daily. Meat, fish, poultry, eggs or dairy product contain vitamin B12.

Question 5

A nurse is reinforcing teaching with a client who is pregnant and has hyperemesis gravidarum about nutrition at home. Which of the following statements indicates that the client understands the teaching?

a. “I will drink water with my meals.”
b. “I will eat every 6 hours throughout the day.”
c. “I will eat crackers before I get out of bed in the morning.”
d. “I will limit my protein intake.”

Answer 5

c. “I will eat crackers before I get out of bed in the morning.”

A client who has hyperemesis gravidarum should eat crackers prior to getting out of bed because carbohydrate consumption can decrease nausea.

Question 6

A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. Incomplete abortion is the initial diagnosis. Which of the following actions should the nurse contribute to the client’s plan of care?

a. Administer oxygen via facemask.
b. Determine the amount and type of vaginal bleeding.
c. Instruct the client in appropriate birth control methods.
d. ​Keep the client on bed rest.

Answer 6

b. Determine the amount and type of vaginal bleeding.

Bleeding can continue until the client has expelled all of the products of conception. It is important for the nurse to note the amount and type of bleeding and to monitor the client for indications of excessive blood loss.

Question 7

A nurse is assisting with the care of a client who is pregnant in an antepartum clinic.
Which of the following findings should the nurse report to the provider?
Select the 4 findings that the nurse should report to the provider.

Vital Signs
0800:
Temperature 36.6° C (97.9° F)
Pulse rate 85/min
Respiratory rate 20/min
Blood pressure 180/99 mm Hg
0815:
Pulse rate 88/min
Respiratory rate 16/min
Blood pressure 178/106 mm Hg
0830:
Pulse rate 84/min
Respiratory rate 18/min
Blood pressure 174/105 mm Hg

Medical History
0815:
Gravida 4 Para 3
33 weeks of gestation
Allergies Sulfa
Height 165 cm (64.96 in)
Weight 82 kg (180 lb)
BMI 30.6
7 lb weight gain over the last 2 weeks

Nurses’ Notes
Client reports, “I have had headache for 2 days. Tylenol does not relieve it. I have blurred vision and dizziness.”
Client reports swelling of their feet.
2+ pitting edema of the lower extremities noted bilaterally.
Deep tendon reflexes 3+, absent clonus
Fetal heart tones (FHT) 150

Answer 7

a. Visual disturbances
b. Deep tendon reflexes
c. Blood pressure
d. Weight

Deep tendon reflexes is correct. The client has deep tendon reflexes of 3+, which is above the expected reference range and requires immediate follow up. Hyperreflexia occurs due to increased central nervous system irritability that is caused from vasospasms and decreased organ perfusion that cause cortical brain spasms. The nurse should report this to the provider.
Visual disturbances is correct. The client reports blurred vision which is caused from vasospasms and decreased organ perfusion causing retinal arteriolar spasms. Increased central nervous system irritability can manifest as visual disturbances. The nurse should report this to the provider.
Fetal heart tones is incorrect. The fetal heart tones are within the expected reference range of 110 to 160/min. The nurse should not report this to the provider.
Blood pressure is correct. The client’s blood pressure is above the expected reference range and requires immediate follow up to rule out preeclampsia. One criterion for evaluating the client’s blood pressure is a systolic blood pressure greater than 30 mm Hg and a diastolic blood pressure greater than 15 mm Hg above the prepregnancy blood pressure values. The nurse should report this to the provider.
Weight is correct. The client has gained 7 lb over the past 2 weeks. This is above the expected weight gain of 1 lb/week. The nurse should report this to the provider.

Question 8

A nurse in a prenatal clinic is reviewing the medical record of a client who is at 28 weeks of gestation. The client’s history reveals one pregnancy terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks of gestation. The nurse should document which of the following as the client’s present parity?

a. 2
b. 3
c. 4
d. 5

Answer 8

a. 2

Parity describes the number of pregnancies that have reached viability, which is a term of 20 weeks, regardless of whether the fetus was born alive. The client’s current pregnancy at 28 weeks of gestation and the pregnancy with the twins who were born at 36 weeks of gestation equals a parity of 2.

Question 9

A nurse is caring for a client who has recurrent herpes simplex type 1 lesions. The nurse should perform a focused assessment of which of the following areas of the client’s body?

a. Mouth
b. Genitalia
c. Extremities
d. Scalp

Answer 9

a. Mouth

Herpes simplex type 1 most commonly occurs on the client’s mouth.

Question 10

A nurse is assisting in the care of a client who is 36 weeks gestation and reported to the clinic for a routine visit.
Which of the following findings should the nurse report to the provider?
(Select all that apply.)

a. Cerebral manifestations
b. Gastrointestinal assessment findings
c. Blood pressure
d. Fetal heart rate
e. Respiratory rate
f. Deep tendon reflexes

Answer 10

a. Cerebral manifestations
b. Gastrointestinal assessment findings is correct.
c. Blood pressure
f. Deep tendon reflexes

Cerebral manifestation is correct. The client has an elevated blood pressure, unrelieved headache for the last several days that has worsened in the last hour, and dizziness. These are manifestations of preeclampsia and should be reported to the provider.
Gastrointestinal assessment findings is correct. The client has an elevated blood pressure, a headache, and epigastric pain. These are manifestations of preeclampsia and should be reported to the provider.
Deep tendon reflexes is correct. The client has an elevated blood pressure, a headache, epigastric pain, and 3 + patellar reflexes. These are manifestations of preeclampsia and should be reported to the provider.
Fetal heart rate is incorrect. The fetal heart rate is 158/minute which is within the expected reference range of 110 to 160/min. Therefore, this finding does not need to be reported to the provider.
Blood pressure is correct. The client has an elevated blood pressure as well as a headache, epigastric pain, and 3 + patellar reflexes. These are manifestations of preeclampsia and should be reported to the provider.
Respiratory rate is incorrect. Due to physiological changes that occur during pregnancy, the pregnant client may have respirations slightly above the expected reference range. Therefore, respiratory rates of 21/min and 22/min do not need to be reported to the provider.

Question 11

A nurse on the postpartum unit is collecting data from a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize this client is at risk for which of the following postpartum complications?

​a. Amniotic fluid embolism
b. Disseminated intravascular coagulation (DIC)
c. ​Preeclampsia
d. ​Puerperal infection

Answer 11

b. Disseminated intravascular coagulation (DIC)

The nurse should recognize that experiencing abruptio placentae places the client at higher risk for DIC. Clinical manifestations of DIC include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.

Question 12

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 12

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 13

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

a. Blot the perineal area dry after voiding.
b. Clean the perineal area from front to back.
c. Perform hand hygiene before and after voiding.
d. Apply ice packs to the perineal area several times daily.
e. Sit on an inflatable donut to protect the perineum.>

Answer 13

a. Blot the perineal area dry after voiding.
b. Clean the perineal area from front to back.
c. Perform hand hygiene before and after voiding.

Blot the perineal area dry after voiding is correct. The nurse should instruct the client to blot the perineal area dry after voiding. Secretions that are allowed to remain on the perineum can be a medium for bacterial growth, which increases the risk for infection. Therefore, the perineal area should be thoroughly dried by blotting after each void.
Clean the perineal area from front to back is correct. The nurse should instruct the client to clean the perineal area from front to back. Cleaning the perineum from front to back decreases the chances of transmitting fecal organisms to other areas, such as the urinary meatus, episiotomy incision, or lacerations resulting from childbirth.
Perform hand hygiene before and after voiding is correct. The nurse should instruct the client to perform hand hygiene before and after voiding. Hand hygiene is the primary method of reducing micro-organisms on the hands, thereby reducing the risk of transmission that can lead to infection.
Apply ice packs to the perineal area several times daily is incorrect. The nurse should not instruct the client to apply ice packs to the perineal area to reduce the risk of infection. Ice packs can be applied to the perineal area for the first 24 hr after birth to decrease edema and to reduce discomfort.
Sit on an inflatable donut to protect the perineum is incorrect. The nurse should not instruct the client to sit on an inflatable donut because this separates the buttocks, which decreases venous blood flow. This does not decrease the client’s risk of perineal infection.

Question 14

A nurse is providing care to a client who is pregnant. Which of the following findings should receive highest priority when providing care?

a. Client’s decreased caloric intake
b. History of anemia
c. Client’s age less than 16
d. Lack of health insurance

Answer 14

c. Client’s age less than 16

When using the greatest risk priority framework, the nurse should identify that and age less than 16, is the highest priority. Adolescent clients are considered high-risk because they could experience low socioeconomic status, late entry into prenatal care, and limited knowledge about self-care knowledge, which can lead to complications during the client’s pregnancy.

Question 15

A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client?

a. “You are immune to rubella.”
b. “You will need an immunization following delivery.”
c. “I will administer the rubella immunization to you today.”
d. “You had the rubella infection as a child.”

Answer 15

b. “You will need an immunization following delivery.”

The negative rubella titer means that the client is susceptible to the rubella virus and needs to be immunized after delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following the rubella immunization, the client should be cautioned not to conceive for 3 months.

Question 16

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

a. Hypoglycemia
b. Decreased RBC
c. Hypobilirubinemia
d. Hypercalcemia

Answer 16

a. Hypoglycemia

​Newborns of clients who have diabetes are at high risk for hypoglycemia as the constant supply of glucose creates fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the new, lesser supply of glucose. Because severe hypoglycemia can lead to cyanosis and seizures, which pose the greatest risk to the newborn at this time, this is the nurse’s highest priority.

Question 17

A nurse is caring for a client who is at 34 weeks of gestation and has a suspected placenta previa. Which of the following actions should the nurse take?

a. Complete a vaginal exam.
​b. Perform a rectal exam.
c. Apply ice to the perineal area.
d. ​Apply an external fetal monitor.

Answer 17

d. ​Apply an external fetal monitor.

The nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

Question 18

A nurse is caring for a client who is at 31 weeks of gestation.

Medical History
Client is at 31 weeks of gestation, gravida 1. Admitted from the provider’s office with a history of a low-lying placenta and active vaginal bleeding for 1 hour. There was a history of spotting at 12 weeks of gestation. Client was placed on bed rest for 2 months with no pelvic rest.
Vital Signs
Oral temperature 36.4° C (97.5° F)
Heart rate 110/min
Respiratory rate 18/min
Blood pressure 88/50 mm Hg
Oxygen saturation 96% on room air
Fetal heart rate 180/min
Diagnostic Results
1000:
Hct 27% (> 33%)
Hgb 8 g/dL (> 11 g/dL)
Platelet count 90,000/mm³ (150,000 to 400,000/mm³)
WBC count 9,000/mm³ (5,000 to 10,000/mm³)
Maternal blood type O+
Ultrasonographic findings reveals:
Placenta location is located in the lower uterine segment.
Fetal position is vertex.
Station of the presenting part is high.
Medication Administration Record
Administer Betamethasone 12 mg IM now and repeat in 24 hours
Nurses’ Notes
0830:
Client is admitted from provider’s office. Client who is at 31 weeks of gestation and reports active vaginal bleeding for the last hour. The client is admitted to the labor and birth unit. Abdomen is soft and nontender. The client denies abdominal pain.
Perineal pad is saturated with bright red vaginal bleeding. FHT 180 beat/min (110 to 160 beats/min) with minimal variability and occasional late decelerations noted.
Fundal height is 30 cm. Blood drawn for type and cross match.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer 18

The nurse should assist with continuous monitoring of contractions and the fetal heart rate, and prepare the client for a cesarean birth because the client is most likely experiencing placenta previa. The client is at risk for hypovolemic shock because of significant blood loss and the well-being of the fetus is at risk. The nurse should monitor the client’s uterine activity and postpartum hemorrhage with a firm fundus because increased uterine activity places the fetus at risk for hypoxia. After surgery, the client’s fundus may be firm, but because of decreased muscle bundles in the lower uterus are absent, the client may still experience postpartum hemorrhage.

Question 19

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 19

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 20

A nurse is assisting in the care of a client who is at 34 weeks of gestation.

Medical History
Gravida 3 Para 2
BMI 31
History of polycystic ovary syndrome

Diagnostic Results
Fasting blood glucose 140 mg/dL (60 to 105 mg/dL)
HbA1c 10% (less than 6.5%)
Urinalysis:
Appearance cloudy
Color amber yellow
pH 4.8 (4.6 to 8.0)
Positive urine glucose (negative)
3+ ketones (negative)
Urine specific gravity 1.010 (1.005 to 1.030)

Vital Signs
Blood pressure 138/76 mm Hg
Heart rate 100/min
Respiratory rate 20/min
Temperature 36.6º C (97.9º F)

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer 20

The nurse should obtain a fasting blood glucose level and perform a nonstress test because the client is most likely experiencing gestational diabetes mellitus. The client has glucose levels above the expected reference range, glucosuria, and ketonuria. The nurse should monitor glycosylated hemoglobin A1c because it evaluates past glycemic control and assists the provider to evaluate how well the client is adhering to the treatment plan. Also, fetal well-being should be monitored to determine how the diabetes is affecting the fetus and if additional studies or testing should be performed on the fetus in addition to nonstress testing.

Question 21

A nurse is collecting data for a female client who has genital herpes. Which of the following findings should the nurse expect?

a. Anuria
b. Dysuria
c. Polyuria
d. Oliguria

Answer 21

b. Dysuria

Symptoms of genital herpes develop 3 to 7 days after skin-to-skin contact with an infected person. Genital herpes lesions appear as small blisters on the genitals. During urination, the client may experience pain. Other symptoms may include fever, muscle weakness, headaches, and burning genital pain.

Question 22

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

a. Uterine enlargement greater than expected for gestational age
b. Copious vaginal bleeding
c. Severe nausea and vomiting
d. Pelvic pain

Answer 22

d. Pelvic pain

The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing pain as the tube stretches.

Question 23

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?

​a. Tachycardia
b. Hypotension
​c. Polyuria
​d. Headache

Answer 23

​d. Headache

Severe preeclampsia causes headache, blurred vision, irritability, nausea, vomiting, hypertension, proteinuria, and edema.

Question 24

A community health nurse is assisting with the development of a program aimed at decreasing health issues among community residents who are pregnant. Using FOCUS-PDSA framework, which of the following steps is the first the nurse will take in the quality improvement process?

a. Identify the prevalence of anemia during pregnancy
b. Compare post-intervention rates of anemia with pre-intervention rates
c. Search for evidence-based resources about anemia during pregnancy
d. Provide a nutrition program for residents who are pregnant

Answer 24

a. Identify the prevalence of anemia during pregnancy

The nurse should identify that identifying the prevalence of anemia is the first step in the PDSA framework: Find a process to improve.

Question 25

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

a. Fetal heart rate irregularities
b. Whitish vaginal discharge
c. Excessive uterine enlargement
d. Rapidly dropping human chorionic gonadotropin (hCG) levels

Answer 25

c. Excessive uterine enlargement

A hydatidiform mole is a rare tumor that arises from placental tissue and results in a rapidly enlarging uterus.

Question 26

A nurse in a prenatal client is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding, without contractions, that started spontaneously. She is in no distress and states that she can “feel the baby moving.” The client should undergo an ultrasound to determine which of the following findings?

a. Fetal lung maturity
b. Location of the placenta
c. Rh incompatibility
d. Frequency and duration of contractions

Answer 26

b. Location of the placenta

Painless, spontaneous vaginal bleeding might be an indication of placenta previa. With the ultrasound, the provider can identify the location of the placenta and urgency of the delivery.

Question 27

A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client’s respiratory rate is 8/min. Which of the following should the nurse administer?

a. Calcium gluconate
b. Flumazenil
c. Naloxone
d. Protamine sulfate

Answer 27

a. Calcium gluconate

The nurse should plan to administer calcium gluconate or calcium chloride as the reversal agent for a client who experiences magnesium sulfate toxicity.

Question 28

A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend?

a. Place elbow restraints on the newborn.
b. Change the newborn’s position every 2 hr.
c. Cluster the newborn’s care activities.
d. ​Allow opportunities for newborn massage.

Answer 28

c. Cluster the newborn’s care activities.

By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation.

Question 29

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

a. Puerperal infection
b. Retained placental fragments
c. ​Thrombophlebitis
​d. Uterine atony

Answer 29

​d. Uterine atony

​This client is at an increased risk for uterine atony due to the birth of a macrosomic newborn. The uterus might contract poorly after birth, increasing the risk for postpartum hemorrhage.

Question 30

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination?

a. Infection
b. Preterm labor
c. Profound bleeding
d. Rupture of the fetal membranes

Answer 30

c. Profound bleeding

​The greatest risk to the client is hemorrhage. The nurse should place the client on pelvic rest, which means no vaginal examinations, no douching, and no vaginal intercourse. This is because any pressure on the placenta could cause its premature separation and life-threatening hemorrhage.