NUR 418 MATERNITY 02 EXAM COMPLETE
QUESTIONS WITH DETAILED ANSWERS AND
RATIONALES |LATEST 2023/2024|
1- When making assignments in the obstetrical unit, the charge nurse should assign the most experienced staff
nurse to which client?
1. G1P0 reporting a small amount of pink vaginal discharge
2. G2P1 reporting rupture of membranes with greenish fluid
3. G3P2 at 7 cm dilation, 100% effacement
4. G4P2 with bilateral +1 pitting ankle edema
Explanation:
If a client reports green amniotic fluid, the nurse should suspect meconium-stained amniotic fluid. Meconium
is the fetal gastrointestinal contents, including toxins and waste, accumulated during pregnancy. Green or
yellow amniotic fluid indicates that the fetus has passed the first stool (meconium) in utero.
Meconium is toxic to the lungs, and its presence in the amniotic fluid places the newborn at high risk for
meconium aspiration syndrome, a type of aspiration pneumonia. Birth will require a neonatal resuscitation
team capable of endotracheal intubation and suctioning. Endotracheal suctioning is indicated if the baby has
depressed respirations, decreased muscle tone, or heart
rate <100/min. (Option 1) Bloody show is usually pink
and is described as "sticky" due to its mucoid nature. It
is an expected finding with labor progression. Light
spotting or brownish discharge may also be an expected
finding following vaginal examination or recent
intercourse due to cervical trauma. However,
spontaneous bright red bleeding is not normal.
(Option 3) Cervical dilation and effacement are signs
of labor progression. This client does not exhibit any
concerning signs of potential complications.
(Option 4) Dependent edema is an expected finding in
pregnant clients. Edema is no longer included in the
definition of preeclampsia due to its prevalence in
healthy pregnancies. Defining characteristics include
increased blood pressure after 20 weeks gestation with
, NUR 418 maternity 02
proteinuria in a previously normotensive client. Educational objective:
Green amniotic fluid indicates the presence of meconium. Meconium aspiration is considered an obstetrical
emergency requiring a skilled neonatal resuscitation team.
2- A neonate is born with exstrophy of the bladder. Which intervention would be appropriate for the nurse to
complete first?
1. Cover the bladder with petroleum jelly gauze
2. Insert a urinary catheter into the bladder
3. Place a protective film over the bladder
4. Prepare the neonate for immediate surgery
Explanation:
Bladder exstrophy is a congenital disorder in which the bladder was not developed in the abdominal cavity
during fusion in the embryo and is exposed externally. The priority before surgical repair is to prevent injury.
Placing a protective film of plastic (Saran wrap) over the exposed bladder will keep the tissue moist and help
prevent infection.
(Option 1) Petroleum jelly in the gauze may be irritating to the delicate bladder tissue and should be avoided.
(Option 2) Inserting a urinary catheter is not an appropriate intervention at birth.
(Option 4) Surgery will be necessary to correct the defect but is not considered an emergent procedure.
Educational objective:
Bladder exstrophy is a congenital anomaly in which the bladder is abnormally formed outside the abdominal
wall and requires surgery to correct. It is imperative to keep the external portion of the bladder moist with a
protective film of plastic before surgery to prevent tissue injury and decrease the risk of infection.
3- A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment
finding is the priority and requires a nursing response?
1. Apgar score of 7 at 1
minute
2. Apical heart rate of 160/min
3. Circumoral duskiness
4. Jitteriness
,NUR 418 maternity 02
Explanation: Infants of diabetic
mothers are at risk of
hypoglycemia and
hypocalcemia. The
transitional time (the first 6
hours after birth) is
especially high risk for
hypoglycemia as the fetus
produced high levels of
insulin in response to the
high levels of circulating
maternal glucose. The
insulin level for a diabetic
mother's neonate remains
higher
than normal in the first few
hours of
extrauterine life, making
the neonate at risk for hypoglycemia.
Hypoglycemia in a newborn is considered a blood glucose level <40 mg/dL (2.2 mmol/L). Symptoms
of hypoglycemia include jitteriness, irritability, hypotonia, apnea, lethargy, and temperature
instability.
(Option 1) An Apgar score of 7-10 indicates a stable status. Apgar assessment is normally performed at 1
minute and 5 minutes after birth. If the 5 minute score is <7, additional scores should be assigned every 5
minutes up to 20 minutes.
(Option 2) Normal neonatal
heart rate is 110- 160/min.
The rate can increase to
180/min with crying and fall
as low as 100/min during
sleep.
Sustained tachycardia
(>160/min) for >10 minutes
indicates possible sepsis,
respiratory distress, or
congenital heart abnormality.
Bradycardia indicates possible sepsis,
increased intracranial pressure, or hypoxia. The neonate's heart rate should be assessed by taking an apical rate
for a full minute (noting the rate and rhythm).
(Option 3) Circumoral cyanosis is a benign, localized, transient cyanosis around the mouth during the
transition period. If it persists, it may be related to a cardiac anomaly. Educational objective:
, NUR 418 maternity 02
Infants of diabetic mothers are at high risk for hypoglycemia, especially in the transition period. A common
symptom of hypoglycemia in a newborn is jitteriness.
4- What would be an appropriate nursing intervention at the birth of a neonate with anencephaly?
1. Discuss the need for physical therapy with the parents
2. Provide comfort care to the neonate
3. Provide genetic counseling to the parents
4. Refer the parents to a support group for children with anomalies
Explanation:
Anencephaly is a neural tube defect that results in very little to no brain tissue forming in utero.
The majority of fetuses with anencephaly will be stillborn. Those born alive will not survive for long. Comfort
care should be provided for the neonate. Drying, bundling, or placing the neonate skin-to- skin with the mother
for warmth and possibly administering oxygen to the neonate will decrease the discomforts of impending death.
Allowing the mother to hold the neonate will assist with the grieving process.
(Option 1) Physical therapy is not indicated for anencephaly. Because little to no brain tissue is present, the
child will not survive long enough to need such treatment.
(Option 3) The parents should be provided genetic counseling as neural tube defects are considered a
congenital anomaly. However, this intervention is not appropriate at the child's birth.
(Option 4) The parents would benefit more from a support group related to loss of a child rather than one for
children born with anomalies. This referral should be made prior to discharge of the mother, not at the child's
birth.
Educational objective:
A neonate with anencephaly is typically stillborn. If the neonate is born alive, death will usually occur shortly
thereafter. Comfort care for the neonate, including warmth and oxygen, should be provided to decrease the
discomforts of impending death.
5- A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent
indicates that further teaching is needed?
"Discharge and odor indicate infection of the circumcision site."
1.
"I will clean the area with alcohol-based wipes or soap water."
2.
"Infant crying during petrolatum gauze changes is expected."
3.
"The diaper should be changed at least every 4 hours."
4.
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