1. 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?

a. Ketonuria

i. Occurs due to the breakdown of fatsecondary to malnutrition orstarvation

2. A 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 report to the provider?

a. Blurred vision

i. An indication that the client might have preeclampsia

3. 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?

a. Neonatal abstinence scoring system

i. Exhibiting manifestations of opioid withdrawal and should be screened

ii. Additional manifestations of withdrawal include restlessness, tremors, increased

muscle tone, and an exaggerated Moro reflex

4. A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions

should the nurse take?

a. Place an opaque mask over the newborn’s eyes

i. To prevent damage to the retinas – remove mask for feedings

5. A nurse is assisting in the care of a newborn immediately following birth. Which of the following

imagesshould the nurse identify as an indication that the newborn was a myelomeningocele?

a. First picture – exposed spinal cord and fluid filled sac, priority intervention isto maintain

the integrity of the sac

i. Myelomeningocele occurs when the neural tube failsto close, and the meninges

and spinal cord herniate

1. Defect most often occursin the lumbar area and may be covered by a

thin membranous sac

6. A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should

the nurse report to the provider?

a. Apical heart rate of 90/min while crying

i. Is below the expected reference range of 110-160 bpm for a newborn; 80-100

bpm while sleeping; and up to 180 bpm while crying

7. A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn.

The client reports perineal pain of 6 on a scale from 0-10. The nurse also notes mild perineal

edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the

right. Which of the following action is the nurse’s priority?

a. Help the client ambulate to the toilet