Maternal-Newborn Nursing Flashcards

A nurse is assessing a newborn at 1 minute after birth. The infant has a heart rate of 90 bpm, weak cry, some flexion, grimace to stimulation, and blue hands and feet. What is the APGAR score?

Answer: 6

HR <100 (1) + weak cry (1) + some flexion (1) + grimace (1) + acrocyanosis (1) = APGAR score of 6.

A patient is 36 weeks pregnant and has a blood pressure of 158/104 mmHg with 3+ proteinuria. The nurse should prepare for management of:

Answer: Severe preeclampsia

BP ≥160/110 with significant proteinuria at or after 20 weeks gestation meets criteria for severe preeclampsia.

Which fetal heart rate pattern requires the nurse to immediately reposition the mother and notify the provider?

Answer: Late decelerations in a non-reactive NST

Late decelerations indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate intervention.

A nurse is caring for a patient in active labor receiving magnesium sulfate. Which finding signals toxicity?

Answer: Loss of deep tendon reflexes

Loss of deep tendon reflexes (DTR) is an early sign of magnesium sulfate toxicity and must prompt immediate action.

A newborn has not passed meconium within 48 hours of birth. The nurse should assess for:

Answer: Hirschsprung's disease or imperforate anus

Failure to pass meconium within 24–48 hours suggests intestinal obstruction such as Hirschsprung's disease or imperforate anus.

Which nursing action is the priority when a prolapsed umbilical cord is identified?

Answer: Place the patient in Trendelenburg or knee-chest position

The priority is relieving cord compression by positioning (Trendelenburg or knee-chest) while calling for emergency assistance.