Maternal Newborn Practice B Assessment 2023

Maternal Newborn Practice B Assessment 2023 19. A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following should the nurse report to the provider? a. Answer: Swelling of the face b. Why?: Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Occurs because renal perfusion is reduced which leads to retention of sodium and water which causes fluids to move out of the intravascular compartment into the tissues leading to edema. c. Varicose veins are expected during the second trimester d. Nonpitting edema of the lower extremities is an expected finding of the third trimester e. Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the second trimester 20. A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? a. Answer: Jitteriness b. Why?: Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Small or large newborns for gestational age and late preterm newborns are at increased risk for hypoglycemia. c. Hypotonia is a manifestation of hypoglycemia d. Abdominal distention is a manifestation of hypocalcemia e. Mottling is a manifestation of opioid withdrawal. 21. A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? a. Answer: I will have blood tests because my potassium might decrease b. Why?: An adverse effect of terbutaline is hypokalemia. c. Administered subcutaneously every 4 hours for no longer than 24 hours d. An adverse effect of terbutaline is hyperglycemia e. An adverse effect of terbutaline is hypotension 22. A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? a. Answer: Temperature b. Why?: Greatest risk for a client following amniotomy is infection 23. A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? a. Answer: Apply cabbage leaves to the breasts b. Why?: Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement c. Use a cold compress to decrease breast discomfort during lactation suppression d. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain e. Tea bags are used to relieve nipple soreness in breastfeeding clients. 24. A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? a. Answer: Determine respiratory function b. Why?: ABCs 25. A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicated an understanding of the teaching? a. Answer: “I will continue taking my insulin if I experience nausea and vomiting.” b. Why?: Continue taking their insulin as prescribed during illness to prevent hypoglycemia and hyperglycemia episodes c. Teach the client to maintain her fasting blood glucose level between 60 and 99 mg/dL d. Teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. e. Teach the client to avoid snacks and foods that are high in refined sugar. 26. A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? a. Answer: Chin quivering b. Why?: Behavioral responses to the newborn’s pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow c. Other signs of the newborn experiencing pain include increase in HR, dilated pupils, rapid and shallow respirations 27. A nurse in the antepartum clinic is assessing a client’s adaptation to pregnancy. The client states that she is, “happy one minute and crying the next.” The nurse should interpret the client’s statement as an indication of which of the following? a. Answer: Emotional lability b. Why?: Rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. c. Focusing phase: 3 rd phase of the father’s emotional response to the pregnancy. Characterized by his active involvement in the pregnancy and his relationship with the child. d. Cognitive restructuring: Accepting the idea of pregnancy and assimilating it into the woman’s life. Degree of acceptance is shown in the mother’s emotional responses.