Question 10
RN Capstone Maternal Newborn. A nurse is assessing a client who is at 35 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse identify as the priority?
- 480 mL urine output in 24 hr
- Blood pressure 144/92 mm Hg
- +1 proteinuria
- Urinary output 40 mL in 2 hr
Question 11
A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider?
- Generalized petechiae
- Heart rate 150/min
- Acrocyanosis
- Blood glucose 50 mg/dL
Question 12
A nurse is preparing to administer magnesium sulfate IV to a client who has preeclampsia. Which of the following actions should the nurse take?
- Monitor the client’s blood pressure every 2 hr.
- Assess the client’s deep tendon reflexes every 4 hr.
- Ensure that calcium gluconate is available.
- Limit the client’s total fluid intake to 100 mL/hr.
Question 13
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip. Which of the following actions should the nurse take?
- Perform a vaginal exam to check for cord prolapse.
- Place the client in a side-lying position.
- Increase the rate of the oxytocin infusion.
- Instruct the client to perform the Valsalva maneuver during contractions.
Question 14
A nurse is providing teaching to a client who is at 30 weeks of gestation and has a prescription for a nonstress test (NST). Which of the following information should the nurse include?
- “You will need to remain NPO for 4 hours before the test.”
- “The test will take about 10 minutes.”
- “You will press a button when you feel the baby move.”
- “You will receive a medication to stimulate contractions.”
Question 15
A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first?
- Administer oxytocin IM.
- Massage the client’s fundus.
- Assess the client’s blood pressure.
- Encourage the client to void.
Question 16
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- Swaddle the newborn with legs flexed.
- Provide frequent eye contact during feedings.
- Weigh the newborn every 48 hr.
- Increase environmental stimuli.
Question 17
A nurse is assessing a client who is in the first stage of labor. The nurse notes that the client’s contractions are every 2 min, lasting 100 seconds, and the fetal heart rate is 100/min. Which of the following actions should the nurse take?
- Discontinue the oxytocin infusion.
- Prepare to administer terbutaline.
- Increase the rate of the IV maintenance fluid.
- Administer oxygen via nonrebreather mask.
Question 18
A nurse is teaching a client who is at 10 weeks of gestation about managing nausea and vomiting. Which of the following instructions should the nurse include?
- “Drink a glass of water with each meal.”
- “Eat three large meals a day.”
- “Eat dry crackers before getting out of bed in the morning.”
- “Brush your teeth immediately after eating.”
Question 19
A nurse is assessing a newborn who is 24 hr old. Which of the following findings should the nurse expect?
- Chest circumference 2 cm less than head circumference
- Length 40 cm (15.7 in)
- Weight 2,000 g (4.4 lb)
- Head circumference 28 cm (11 in) RN Capstone Maternal Newborn
Question 29
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn’s head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- Caput succedaneum
- Cephalohematoma
- Erythema toxicum
- Mongolian spots
Question 30
A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full-term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client’s obstetrical history as which of the following?
- Gravida 3, Para 3
- Gravida 3, Para 2
- Gravida 4, Para 3
- Gravida 4, Para 2
Question 33
A nurse is caring for a client who has a prescription for ibuprofen to treat postpartum cramping. Which of the following questions should the nurse ask prior to administering the medication? (Select all that apply.)
- “What kind of contraception will you be using?”
- “Are you being treated for high blood pressure?”
- “Do you have a history of cataracts?”
- “Are you taking over-the-counter medications?”
- “Do you have a history of gastric problems?” RN Capstone Maternal Newborn
Question 35
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- “Increase your potassium intake.”
- “Increase your fluid intake to 3 liters per day.”
- “Refrain from consuming alcohol.”
- “Limit your daily intake of fiber.”
Question 36
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- Initiate continuous monitoring of the FHR.
- Administer a dose of betamethasone.
- Check the cervix for dilation every 8 hr.
- Request that the provider prescribe misoprostol PRN.
Question 37
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- “You should keep the car seat rear-facing until your baby is at least 2 years old.”
- “Position the retainer clip over the upper part of your baby’s abdomen.”
- “You should place your baby in the car seat at a 90-degree angle.”
- “Place the shoulder harness straps in the slots an inch above your baby’s shoulders.”
Question 38
A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply.)
- Nulliparity
- History of breastfeeding
- Previous use of oral contraceptives
- History of breast cancer
- Use of postmenopausal estrogen
Question 39
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- “If my partner is Rh-negative, I will not receive the shot.”
- “I will receive the shot after delivery if my baby is Rh-negative.”
- “I should not receive any immunizations for 3 months after the shot.”
- “This shot may be given after birth to protect future pregnancies.”
Question 40
A nurse providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include in the teaching?
- Peanut butter sandwich
- Sliced apples
- Glass of skim milk
- Scrambled egg
Question 41
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
- Respiratory rate 11/min
- Deep tendon reflexes 2+
- Urine output 30 mL/hr
- Blood pressure 100/62 mm Hg
Question 42
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- Prepare the necessary equipment to initiate an amnioinfusion.
- Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- Discontinue the infusion of oxytocin.
- Provide instructions for the client about potential preparation for birth.
Question 43
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?
- Discourage the client from looking at their breasts.
- Recommend a support group for the client to attend.
- Tell the client you are so sorry for how devastated they must feel.
- Tell the client to focus on their postoperative recovery for now.
Question 44
A nurse is reviewing the laboratory results of a newborn who is 32 hr old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?
- WBC count 35,000/mm³ (9,000 to 30,000/mm³)
- Glucose 35 mg/dL (greater than 40 to 45 mg/dL)
- Bilirubin 14.0 mg/dL (1.0 to 12.0 mg/dL)
- Platelet count 350,000/mm³ (150,000 to 300,000/mm³)
Question 45
A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)
- Instruct the client to wash their hands prior to breastfeeding.
- Teach the client about proper latching-on techniques.
- Encourage the client to alternate breastfeeding with formula feeding.
- Instruct the client to avoid using a breast pump.
- Encourage the client to allow their nipples to air dry after feedings.
Question 46
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- Hyporeactivity
- Excessive high-pitched cry
- Acrocyanosis
- Respiratory rate of 50/min
Question 47
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?
- BUN 30 mg/dL (10 to 20 mg/dL)
- Hgb 9.9 g/dL (11 to 16 g/dL)
- Serum uric acid 2.5 mg/dL (2.7 to 7.3 mg/dL)
- Casual blood glucose 228 mg/dL (less than 200 mg/dL)
