the Point; Maternal Benchmark I

Question 2 of 50

the Point; Maternal Benchmark I. A nurse plans a teaching session for parents of toddlers about the prevention of ingestion of poisoning. What does the nurse include in teaching?

• Methods to administer syrup of ipecac.
• The reduced incidence of poisoning in this age group.
• Ways to induce vomiting after an ingestion.
• Having easy access to the poison control phone number.

Question 3 of 50

The nurse cares for a group of newborns in the newborn nursery. Which action is most important to reduce the risk of infection?

• Isolation of newborns with infection.
• Hand hygiene before touching any newborn.
• Administration of hepatitis B immunizations to all newborns.
• Eye prophylaxis for chlamydia within the first hour of birth.

Question 4 of 50

The nurse assesses the parent’s ability for newborn care during a return demonstration of the newborn bath technique. Which step causes the nurse to be concerned?

• Wipes each eye from inner to outer corner with a separate moistened cotton ball.
• Tests the tub of soapy water for the correct temperature using her elbow.
• Each external ear area is washed with the washcloth; no cotton swabs are used.
• Washes the newborn face without applying soap.

Question 6 of 50

A 9-year-old child is to have a chest tube inserted in a few minutes on an emergent basis. Which is the most appropriate method to prepare this child for the procedure?

• Provide a video that shows chest tube insertion.
• Expedite the process without preparation.
• Develop a behavioral contract about the insertion.
• Offer a brief explanation of the procedure.

Question 7 of 50

A 7-month-old infant with a history of prematurity is admitted to the pediatric unit with a provisional diagnosis of respiratory syncytial virus bronchiolitis. Which isolation procedures should the nurse implement?

• Wearing a high-particulate filter mask when entering the room.
• Placing the client in a negative pressure ventilated room. the Point; Maternal Benchmark I
• Ensuring that the client is assigned to a private room.
• Donning gown, gloves, and face mask upon entrance to the room.

Question 8 of 50

The nurse receives a hand-off report for a group of clients on the postpartum unit. Which client will the nurse assess first?

• The client who is 24 hours postpartum, is receiving magnesium sulfate for preeclampsia and reports an “upset stomach.”
• The client who is 12 hours postpartum, becoming frustrated with breastfeeding and is asking for a bottle to feed her baby.
• The client who is 4 hours postpartum and had 10 cm of lochia rubra on her pad in the last hour.
• The client who is 2 hours postpartum, had an intrapartum epidural and hasn’t voided since birth.

Question 9 of 50

The nurse prepares a family for discharge after the birth of a new baby. Which statements by the parents require additional follow-up?

Select all that apply.

• “I will put several inches of water in her bath, so she doesn’t get cold.”
• “I will keep my baby’s car seat facing forward so I can see her if she has trouble breathing.”
• “I will line my baby’s crib with bumper pads, so she doesn’t hit her head if she rolls over.”
• “I will place my baby on her side to sleep so that if she spits up, she will not choke on it.”
• “I will keep my baby in my room at night, but not in my bed, so that I can respond to her quickly.”

Case Study

A child is admitted from surgery after repair of a ruptured intestine. The client’s intestine was ruptured following an attempted reduction of intussusception.

Orders (4/21)

• NPO
• Bedrest until fully awake.
• Morphine 1-2 mg IV PRN pain.
• Maintain IV fluids at 50 mL/hr with D5​ 1/2 NSS, call provider for potassium prescription when client voids.
• Notify the surgeon if the client experiences vomiting, abdominal distension, or no bowel sounds in 4 hours.

Which concerns the nurse most about the health care provider’s prescriptions in the electronic health record?

• The choice of intravenous fluids prescribed.
• The need for a diet prescription.
• The activity order is too restrictive.
• The lack of a prescription for antibiotics.

Case Study

The nurse cares for a 7-month-old client.

Nursing Notes:

7 month old client received from the OR following internal ventriculoperitoneal (VP) shunt insert secondary to hydrocephalus. Client alert and quiet. Parents at bedside. Dressings dry and intact on abdomen and right scalp. Pupils reactive and equal. Vital signs stable. Breath sounds clear. Bowel sounds hypoactive but present in all four quadrants. Intravenous device in right arm infusing well.

Click to highlight the health care provider order the nurse should plan to implement first.

Orders

• Elevate HOB 10-20 degrees.
• Maintain the IV D_5 1/4 NSS at 45 mL/hr.
• Morphine sulfate 1 mg IVPB PRN pain. the Point; Maternal Benchmark I
• May breastfeed when fully awake.

Question 13 of 50

The nurse cares for a client in the first trimester of pregnancy who has been on levothyroxine prior to her pregnancy. The health care provider prescribes a prenatal vitamin and iron supplement at her first prenatal appointment. The nurse should provide teaching on which priority focus?

• “You will be on this same dose of levothyroxine for the entire pregnancy.”
• “You will need to stop taking these medications while breastfeeding your baby after birth.”
• “Take the levothyroxine an hour before breakfast and the prenatal vitamin and iron at lunch.”
• “Take all of these medications with breakfast every day, so you don’t forget to take them.”

Question 14 of 50

The nurse provides care for a newborn of a mother with type O-positive blood. The nurse is aware that the newborn is at risk for ABO incompatibility. Which is the most appropriate action by the nurse?

• Assessing for jaundice.
• Obtaining a direct Coombs test.
• Preparing for a blood transfusion.
• Monitoring for signs of hypoglycemia.

Question 15 of 50

A newborn is assessed following birth using the APGAR scoring system. The newborn’s scores are 9 at one minute and 9 at five minutes.

Which APGAR criteria should the nurse anticipate caused the deduction of the point as part of this assessment? the Point; Maternal Benchmark I

• The heart rate remains below 100 beats per minute.
• The infant is positioned with flexion of the extremities.
• The infant has a weak, high-pitched cry.
• The extremities of the infant are blue with the body pink.

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Question 16 of 50

The nurse assesses the results of a non-stress test performed on a client who is at 37 weeks’ gestation and has type 1 diabetes. The fetal monitoring indicated multiple increases in fetal heart rate above the baseline fetal heart rate, associated with fetal movement as reported by the client, throughout the 20-minute monitoring period. How does the nurse document this finding?

• Nonreactive test
• Reactive test
• Normal test
• Equivocal

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Question 17 of 50

A hospitalized 1-month-old infant continues to demonstrate signs of neonatal abstinence syndrome. Which nursing interventions does the nurse anticipate?

• Administer intravenous sedation therapy to the client as needed.
• Implement seizure precautions, including oxygen at the bedside.
• Provide high glucose Similac to increase the client’s level of consciousness.
• Provide intravenous fluids at twice the daily maintenance rate.

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Question 18 of 50

The nurse cares for a client in active labor. When preparing to perform a vaginal examination, the membranes rupture, and the nurse discovers a loop of umbilical cord protruding through the vagina. What is the nurse’s priority action?

• Notify the health care provider immediately.
• Immediately turn the client on her side and listen to fetal heart tones.
• Administer oxygen by a nonrebreather mask at 8-10 L/minute.
• Proceed with the vaginal exam and apply upward pressure to the fetal head.

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Question 19 of 50

The nurse administers magnesium sulfate at 2 g/hour as a tocolytic to a client at 30 weeks gestation. Which nursing assessment is priority? the Point; Maternal Benchmark I

• Contraction pattern
• Deep tendon reflexes
• Intake and output
• Blood pressure

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Question 20 of 50

A nurse teaches an 11-year-old client about the use of an inhaler and the need for a spacer. Which statement by the client indicates a good understanding of the use of a spacer?

• “The spacer will push the medication deep into my lungs.”
• “The spacer will stop the medication from escaping into the air when I use it.”
• “I should only use the spacer when my inhaler is getting low.”
• “The spacer makes sure that I don’t get too much medicine at one time.”

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Question 21 of 50

The nurse cares for a client in latent labor. The cervix is 3 cm dilated, and membranes are intact. Which non-pharmacological interventions are most appropriate for comfort and to prevent complications? Select all that apply.

• Provide sips of fluids, ice chips, and a soft diet as prescribed and desired.
• Allow positioning the client finds comfortable.
• Encourage ambulation to the bathroom or in the hall as desired. the Point; Maternal Benchmark I
• Maintain continuous internal electronic fetal monitoring while on bedrest.
• Soaking in a bath, checking fetal heart tones by doppler periodically.

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Question 22 of 50

Case Study: Pediatric Triage

The nurse in a pediatric clinic is triaging a client presenting for a well-child appointment. The nurse suspects the child may have experienced abuse based on which assessment findings? Select all that apply.

• Guarding of left arm during assessment
• Acting out behavior during assessment
• Consistent crying during entire assessment
• Three urinary tract infections in past 12 months
• Multiple minor bruises on both shins

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Question 23 of 50

Case Study: 2-Year-Old Client (Roseola)

Complete the diagram to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Potential Condition

• Roseola

Actions to Take

• Teach parent about comfort measures
• Encourage return to daycare when rash subsides

Parameters to Monitor

• Seizure activity
• Return to typical behaviors and oral intake

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Question 24 of 50

Case Study: Labor Progression Status

Complete the sentences to reflect the client’s progression through the stages of labor based on the electronic health record.

• Based on the client assessment, the client was most likely in the ACTIVE phase of the FIRST stage of labor when admitted at 2310. The client progressed to the SECOND stage of labor at 0325.

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Question 25 of 50

Case Study: Sickle Cell Vaso-Occlusive Crisis

The nurse cares for a 6-year-old child who has a history of sickle cell anemia. The child is being admitted for a vaso-occlusive crisis. Which nursing interventions are appropriate for this client? Select all that apply.

• Administer oxygen as prescribed.
• Apply cold compresses to painful joints.
• Apply warm compresses to painful joints.
• Maintain intravenous (IV) fluid at the prescribed rate.
• Restricted fluid intake to avoid fluid overload.
• Administer parenteral analgesics around the clock as prescribed.

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Question 26 of 50

Case Study: Sickle Cell Crisis Diagram

Complete the diagram to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Potential Condition

• Sickle cell crisis

Actions to Take

• Maintain IV fluids
• Administer analgesics

Parameters to Monitor

• Pain level
• Hydration status

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Question 27 of 50

Case Study: Fourth Stage of Labor

The nurse assesses a client in the fourth stage of labor. Which finding would the nurse expect?

• Firm fundus, midline, at or below the level of the umbilicus.
• Moderate rubra lochia with a few small clots.
• Client reporting mild to moderate cramping or afterpains.
• Mild transient tachycardia and increased blood pressure.

Question 28

The nurse observes that a 15-year-old client seems to ignore the newborn and spend time on social media. Which strategy would the nurse use to facilitate parent-infant attachment?

• Demonstrate for the client different positions for holding the baby while feeding.
• Arrange for the client to watch a video about parent-infant interaction.
• Show the client how the baby initiates interaction and attends to the client.
• Tell the client that they must pay attention to the baby.

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Question 29

The nurse assesses fetal heart rate patterns for a client in active labor. Earlier in the day, the baseline fetal heart rate was 140 beats/min. Now the baseline is 170 beats/min. Which situations may cause this change?

Select all that apply.

• Narcotic administration
• Fetal movement
• Uteroplacental insufficiency
• Maternal fever
• Fetal distress

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Question 30

An unlicensed assistive personnel (UAP) assists with the care of a client on postpartum day one. Which tasks would be appropriate for the nurse to delegate to the UAP?

Select all that apply.

• Helping the mother with ambulation.
• Reinforcing good hygiene while assisting the mother with peri-care.
• Discussing postpartum depression with the mother if the UAP sees her crying.
• Checking the location of the fundus before ambulating the client.
• Helping the mother latch the infant onto her breast.
• Changing the perineal pad and reporting the drainage.

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Question 31

The nurse suctions a pediatric client who has a tracheostomy. Which steps should the nurse include in this procedure?

Select all that apply.

• Instill a small amount of normal saline drops to liquify secretions.
• Maintain constant suction during withdrawal of the suction catheter.
• Swirl the catheter while withdrawing the suction catheter.
• Hyperoxygenation via bag and mask prior to suctioning.
• Maintain suction on the catheter during the insertion of the catheter.
• Apply intermittent suction on the catheter while withdrawing.

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Question 32

A client who is diagnosed with diabetic ketoacidosis is to receive an insulin infusion. The hospital formulary indicates that insulin is administered at 0.1 units/kg/hour. The client weighs 68 pounds. What is the client’s hourly rate of insulin?

Round to the nearest tenth. the Point; Maternal Benchmark I

• 3.1 units/hour

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Question 34

The nurse is reviewing a client’s lab values at the first prenatal visit. Which situation requires further evaluation?

• White blood cells less than 10,000
• Platelet level 150,000
• Rubella titer less than 1:8
• Hemoglobin 11 g/dL

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Question 36

A 5-month-old infant is brought to the primary care office by a parent for a well-child visit. The nurse speaks with the parent about the introduction of solid foods. Which statement by the parent indicates a good understanding of teaching?

• “My other children started solid food at an earlier age, so I will probably do the same with this baby.”
• “I really want my baby to sleep through the night, so I’m going to start giving her cereal before bedtime.”
• “My baby is interested when we eat and has started to grab for food, so I think she is ready.”
• “I noticed that when I put the pacifier in her mouth, she pushes it out with her tongue, so that means she is hungry for real food.”

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Question 37

A client at 34 weeks gestation who is diagnosed with preeclampsia is being treated with magnesium sulfate. Which assessment finding would indicate magnesium toxicity?

• Proteinuria of 3+
• Deep tendon reflexes of 2+
• Respiratory rate of 14 breaths/min
• Urinary output of 20 mL/hour

Question 37 of 50

A 13-year-old client with a history of Crohn’s Disease presents to the school nurse’s office with abdominal pain and an increased frequency of diarrhea. The client shares his plan of care with the school nurse. Which should the school nurse anticipate are part of this plan of care?

Select all that apply.

• Nocturnal nasogastric feedings
• Vitamin and mineral supplementation
• Low-dose oral steroids
• Oral methotrexate
• Unrestricted oral intake
• Total parenteral nutrition while on enteral feedings

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Question 1

The nurse prepares to administer the prescribed methylergonovine to a client.

Click to highlight the data that contraindicates the administration of this medication. Select one option.

Nursing Notes 0250 G5P5 client, 1 hour post vaginal delivery of 9 lbs. 1 oz. (4.110 kg) neonate. Client experiencing heavy postpartum bleeding with large clots. Fundal massage attempted. Fundus remains boggy at umbilicus. Oxytocin 20 units in 1000 mL lactated Ringer’s solution started into peripheral IV. Second peripheral IV started. 0315 Client continues to experience mild postpartum hemorrhage. Indwelling urinary catheter inserted and bladder emptied. Oxytocin infusing. Fundus remains boggy at umbilicus with moderate bleeding. Provider prescribes further uterotonic medication, methylergonovine 0.2 mg IM x 1 dose now, to promote uterine contractions. the Point; Maternal Benchmark I

Vital Signs Time 0250 Blood Pressure: 138/88 Heart Rate: 88 Respiratory Rate: 20 Temperature: 99.5 °F 37.5 °C SpO2: 94% RA

Time 0305 Blood Pressure: 135/85 Heart Rate: 89 Respiratory Rate: 20 Temperature: 99.5 °F 37.5 °C SpO2: 94% RA

Time 0320 Blood Pressure: 144/92 Heart Rate: 88 Respiratory Rate: 20 Temperature: 99.5 °F 37.5 °C SpO2: 92% RA

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Item 1 of 6

Case Study

A nulligravida client presents to clinic with suspicions of being pregnant.

For each client finding, click to specify if the finding is a presumptive, probable, or positive sign of pregnancy.

• Goodell sign: Probable
• Visualization of fetus via ultrasound: Positive
• Fatigue: Presumptive
• Laboratory report (Positive urine hCG): Probable
• Menstrual changes (Amenorrhea): Presumptive
• Breast tenderness: Presumptive
• Auscultation of FHR via ultrasound: Positive
• Hegar sign: Probable

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Item 2 of 6

Based on the information in the electronic health record, which statements should the nurse include in client education? Select all that apply.

• “It is important to begin taking a prenatal vitamin with folic acid daily for the health of your growing fetus.”
• “You will need to return to the clinic at 24 weeks’ gestation and then be seen every two weeks until you deliver.”
• “Exercise is not recommended during pregnancy. If you currently exercise regularly, you may do low impact stretching such as yoga.”
• “Soaking in a hot tub for 30-60 minutes a day may help alleviate some of the back pain you may experience during pregnancy.”
• “Sexual intercourse is safe to practice during pregnancy as long as you don’t experience any bleeding or complications.”
• “Avoid eating hot dogs or soft cheeses. Make sure any meat you eat is thoroughly cooked before you eat it.”
• “Report any vaginal spotting or bleeding, painful urination, or severe and persistent vomiting to your provider immediately.”
• “Increase your daily calorie intake by about 300 calories/day. Normal weight gain during pregnancy for your BMI will be 25-35 lbs. total.”
• “Do not eat any kind of fish during your pregnancy as it may contain mercury, which is harmful to your fetus.”

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Item 3 of 6

Case Study

A nulligravida client presents to clinic with suspicions of being pregnant.

The nurse reviews the client’s laboratory results. Evaluate the nurse’s statements based on the findings.

• “I will arrange an appointment with a dietician to help you with a healthy diet.”: Indicated
• “We will need to monitor your HbA1c levels every 4-6 weeks for the duration of your pregnancy.”: Not Indicated
• “If your blood sugars remain elevated despite a healthy diet, you may need to take insulin for the duration of your pregnancy.”: Indicated
• “The 1-hour glucose tolerance test confirmed your diagnosis. The 3-hour glucose tolerance test tells us how severe your diagnosis is.”: Not Indicated
• “Your blood glucose results were high, but not high enough to indicate gestational diabetes.”: Not Indicated
• “We will need to monitor your baby’s growth weekly as your high blood sugar levels may result in poor growth and a small baby.”: Not Indicated

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Item 4 of 6

A nulligravida client presents to clinic with suspicions of being pregnant. The client returns for a visit at 32 weeks’ gestation.

Complete the following sentences by choosing from the lists of options.

The nurse knows the client is experiencing [Select Option] as a result of [Select Option]. The nurse’s priority action is to [Select Option].

• The nurse knows the client is experiencing: supine hypotension / dehydration / hypoglycemia
• as a result of: client position / lower extremity edema / gestational age
• The nurse’s priority action is to: reposition client to side / offer a sugary snack / provide emesis basin

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Item 5 of 6

The client returns for a visit at 32 weeks’ gestation. Based on the client’s current clinical presentation, click to specify if the intervention is anticipated or contraindicated for the client’s plan of care.

• Betamethasone 12 mg IM: Anticipated
• Magnesium sulfate bolus and continuous infusion: Anticipated
• Amniocentesis: Anticipated
• Nifedipine 10 mg orally: Anticipated
• Perform a vaginal exam: Contraindicated
• Ambulate to the bathroom: Contraindicated
• Place in a supine position: Contraindicated