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CMS Maternal Newborn Practice A
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CMS Maternal Newborn Practice A...
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CMS Maternal Newborn Practice 2024-2025 AA nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse notify the provider about?
- Answer Blurred vision - sign of preeclampsia
Expected findings: non pitting ankle edema, 10 fetal movements in 2 hr, leg cramps
A nurse is caring for a newborn receiving phototherapy. Which of the following nursing
action is appropriate? Place an opaque mask over the newborn eyes - prevents damage
to the retinas
Remove mask during feedings
DO NOT apply a thin layer of lotion on the newborn skin
A nurse is caring for a client who is at 11 weeks of gestation and reports frequent
vomiting. Which of the following findings should the nurse identify as an indication that
the client has hyperemesis gravidarum? - Answer Ketonuria
Occurs due to the breakdown of fat secondary to malnutrition or starvation
Tachycardia and tachypnea due to dehydration
A nurse is caring for a newborn who has a high-pitched cry and does not respond to
consoling efforts. Which of the following neonatal data collection tools should the nurse
expect to complete? - Answer Neonatal Abstinence Scoring System: exhibiting opioid
withdrawal
Additional manifestations: restlessness, tremors, increased muscle tone, and an
exaggerated Moro reflex
- Apgar score: heart rate, respiratory rate, muscle tone, reflex irritability and skin color
Newborn Hearing Screen should be completed before the newborn is being discharged
from the hospital. Critical Congenital Heart Disease screen should be completed 24 – 28
,hours following birth and before the newborn is discharged from the hospital.
A nurse is assisting with caring for a newborn directly after birth. Which of the following
pictures should the nurse recognize as a sign that this newborn has a
myelomeningocele? - Answer Occurs when neural tube does not close, and meninges
and spinal cord herniate
Occurs in lumbar area and maybe covered by a thin membranous sac
Exstrophy of bladder: -abnormal development of abdominal wall, symphysis pubis and
bladder. Present in suprapubic area. Visible and requires surgery in neonatal period .
Omphalocel: Herniation of abdominal organs through umbilical ring at base of umbilical
cord.
-Cephalohematoma; collection of blood between the skull bone and its covering, the
periosteum. A cephalohematoma does not cross the suture lines of the newborn's skull
and will spontaneously resolve in 2-8 weeks
A nurse is performing data collection on an 8hr old newborn. The following finding
should be communicated to the provider: -Answer Apical heart rate of 90/min while
crying-normal range 110 - 160 for a newborn, heart rate of 80-100/min while asleep and
up to 180/min while crying
-Apneic episode of 20 seconds or less Within normal limits; normal for newborn's
respirations to be shallow and irregular -Moro reflex present positive from birth up to 8
weeks -Vernix in the skin folds Normal
A nurse is caring for a client 6 hr after a vaginal birth who will be breastfeeding her
newborn. The client reports her perineal pain as 6 on a scale from 0 to 10. The nurse
also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the
umbilicus and deviated to the right. Which of the following actions is the nurse's
priority?
a. administer analgesics
b. apply an ice pack to the perineum
c. assist the client with breastfeeding
d. help the client ambulate to the toilet - Answer d. help the client ambulate to the toilet
, Thus, the greatest risk for this client is postpartum hemorrhage from uterine atony. The
priority intervention by the nurse would be to assist the client in voiding and emptying
the bladder completely; this would allow the uterus to contract.
A nurse is reinforcing teaching with a client who is at 20 wks of gestation and has
gestational diabetes mellitus. Which of the following information should the nurse
include in the teaching?
a. exercise before meals
b. consume at least 2,000 cal/day
c. avoid consuming an evening snack
d. maintain a fasting blood glucose of 110 to 120 mg/dL - Answer b. consume at least
2,000 cal/day
This will ensure adequate intake of glucose and prevent hypoglycemia. Exercise after
meals to prevent hypoglycemia. Evening snacks are a must to avoid hypoglycemia
during the night. Should maintain a fasting blood glucose less than 95 mg/dL.
A nurse is reinforcing teaching about risk factors for respiratory distress syndrome in
newborns with a group of clients who are pregnant. Which of the following risk factors
should the nurse include?
a. cord compression
b. chronic hypertension
c. alcohol use during pregnancy
d. prematurity - Answer d. prematurity
A premature newborn will have very insufficient production of surfactant and hence may
develop RDS. Alcohol syndrome may result in fetal alcohol syndrome, developmental
delay, and congenital defects. Cord compression may lead to fetal anoxia.
A nurse is caring for a client who is planning to become pregnant. The client asks the
nurse why folic acid supplements are necessary. The nurse should inform the client that
the purpose of the folic acid supplement is to do which of the following? a. facilitate the
storage of iron in the fetus liver b. prevent certain kinds of birth defects c. inhibit
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