Maternal and Newborn Care Flashcards

A nurse is assessing a newborn and notes the Moro reflex is absent on the right side only. This finding most likely indicates:

Answer: Possible brachial plexus injury (Erb's palsy)

A unilateral absent Moro reflex suggests brachial plexus injury (Erb's palsy), often associated with shoulder dystocia or difficult delivery.

A postpartum client reports saturating more than one perineal pad per hour for two consecutive hours. The nurse's priority action is to:

Answer: Assess uterine fundal tone and notify the physician

Saturating more than one pad per hour indicates postpartum hemorrhage; the nurse must immediately assess uterine tone and notify the physician.

When performing a newborn assessment using the APGAR score at 5 minutes, which score indicates the newborn requires continued close monitoring but no immediate resuscitation?

Answer: Score of 4–6

An APGAR score of 4–6 at 5 minutes indicates the newborn needs continued close monitoring and possible stimulation but typically does not require immediate resuscitation.

A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. Which assessment finding requires the nurse to stop the infusion immediately?

Answer: Respiratory rate of 10 breaths per minute

A respiratory rate of 10 breaths per minute indicates magnesium toxicity and is a critical finding requiring immediate cessation of the infusion.

A nurse assesses a client who is 12 hours postpartum and notes the uterine fundus is firm, displaced to the right, and located above the umbilicus. The most appropriate intervention is:

Answer: Assist the client to void or catheterize if unable to void

A displaced, elevated uterine fundus indicates bladder distension; assisting the client to void will allow the uterus to return to the midline.

A client who is 28 weeks pregnant arrives reporting decreased fetal movement. The nurse prepares for which initial assessment?

Answer: Non-stress test (NST)

A non-stress test (NST) is the initial, non-invasive assessment used to evaluate fetal well-being when decreased fetal movement is reported.

A nurse is teaching a client about warning signs to report after discharge at 48 hours postpartum. Which symptom warrants immediate medical attention?

Answer: Calf pain, redness, and swelling in one leg

Unilateral calf pain, redness, and swelling are signs of deep vein thrombosis (DVT), a serious postpartum complication requiring immediate evaluation.