321 Exam 3

The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? 1. "Sometimes babies just don't deliver the way we expect them to." 2. "With all of your preparations, it must have been disappointing for you to have had a cesarean." 3. "I know you had to have surgery, but you are very lucky that your baby was born healthy." 4. "At least your husband was able to be with you when the baby was born."

2. This comment conveys sensitivity and understanding to the client. 1. This comment is inappropriate. It does not acknowledge the client's likely disappointment about having to have a cesarean section. 3. This comment may be true, but it does not acknowledge the client's likely disappointment about having to have a cesarean section. 4. This comment may be true, but it does not acknowledge the client's likely disappointment about having to have a cesarean section.

On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? 1. Breastfeeding is contraindicated if the mother smokes cigarettes. 2. Breastfeeding is protective for the baby and should be encouraged. 3. A 2-pack-a-day smoker should be reported to child protective services for child abuse. 4. A mother who admits to smoking cigarettes may also be abusing illicit substances.

2. This is true. Breastfeeding is protective of the baby and should be encouraged. __________________________________ 1. Although it is recommended that the mother stop smoking, breastfeeding is not contraindicated when the mother smokes.

A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O- (negative), the baby's type is A (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week in order to receive her RhoGAM injection. 2. Carefully check the record to make sure that the RhoGAM injection was administered. 3. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

2. This response is correct. The nurse should not finalize an Rh" (negative) client's discharge until the client has received her RhoGAM injection. Rh" (negative) client's body from mounting a full antibody response to the delivery of an Rh! (positive) baby

Why are obstetric clients most at high risk for cardiovascular compromise during the one hour immediately following a delivery? 1. Because the weight of the uterine body is significantly reduced. 2. Because the excess blood volume from pregnancy is circulating in the woman's periphery. 3. Because the cervix is fully dilated and the lochia flows freely. 4. Because the maternal blood pressure drops precipitously once the baby's head emerges.

2. This response is true. Once the placenta is birthed, the reservoir for the mother's large blood volume is gone.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2. This statement is accurate. Mothers often do not feel bladder pressure after delivery

A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform in order to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 1. The baby should be placed "tummy-totummy" with the mother. Babies cannot swallow when their heads are turned. They must face the breast for effective feeding. 2. To achieve an effective latch of both the nipple and the areolar tissue, the baby must have a wide-open mouth. 3. Because the neonate's mouth muscles are relatively weak, it is important for the baby to be placed at the level of the breast. If the baby is placed lower, he or she is likely to "slip to the tip" of the nipple and cause nipple abrasions. 4. Babies latch best when they are positioned at the breast, in preparation to opening their mouths, with their noses pointed toward their mothers' nipples. 5. The baby's tongue must be below the nipple to achieve effective suckling.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2. Well-approximated edges.

A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In Ortolani sign, the thighs are gently abducted. If the trochanter displaces from the acetabulum, the result is positive and indicative of developmental dysplasia of the hip.

A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure. 2. Avoid puncturing the lateral heel to prevent damaging sensitive structures. 3. Blot the site with a dry gauze after rubbing it with an alcohol swab. 4. Grasp the calf of the baby during the procedure to prevent injury.

3. Alcohol can irritate the punctured skin and can cause hemolysis 1. The foot should be covered with a warm wrap to draw blood to the area for the heel stick. 2. The lateral heel is the site of choice because it contains no major nerves or blood vessels. 4. The ankle and foot should be firmly grasped during the procedure.

A baby has been admitted to the neonatal nursery whose mother is hepatitis B-surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1. Monitor the baby for signs of hepatitis B. 2. Place the baby on contact isolation. 3. Obtain an order for the hepatitis B vaccine and the immune globulin. 4. Advise the mother that breastfeeding is absolutely contraindicated.

3. Babies exposed to hepatitis B in utero should receive the first dose of hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery to reduce transmission of the virus.

The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatalogist? 1. 1-day-old, HR 110 beats per minute in deep sleep. 2. 2-day-old, T 97.7ºF, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3. Babies who breastfeed fewer than 8 times a day are not receiving adequate nutrition. Jitters are indicative of hypoglycemia.

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5ºF? 1. Blood glucose of 50 mg/dL. 2. Acrocyanosis. 3. Tachypnea. 4. Oxygen saturation of 96%.

3. Babies who have cold stress syndrome will develop respiratory distress. One symptom of the distress is tachypnea. _______________________________ Acrocyanosis—bluish hands and feet—is normal for the neonate during the first day or two.

A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that further teaching by the nurse is needed? 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The MMR (measles, mumps, and rubella) immunization should be administered before the first birthday. 4. Three DTaP (diphtheria, tetanus, and acellular pertussis) shots will be given during the first year of life.

3. Because the baby has received passive immunity from the mother, the MMR is not given until the second year of life.

A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? 1. Blood urea nitrogen and serum creatinine. 2. Alkaline phosphotase and bilirubin. 3. Hearing and vision assessments. 4. Peak expiratory flow and blood gas assessments.

3. Because the central nervous system (CNS) may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessments are appropriate.

A 42-week gravida is delivering her baby. A nurse and pediatrician are present at the birth. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? 1. Stimulate the baby to breathe. 2. Assess neonatal heart rate. 3. Assist with intubation. 4. Place the baby in the prone position

3. Before breathing, the baby must be intubated so that the meconium contaminated fluid can be aspirated from the baby's airway. 1. Because meconium is present in the amniotic fluid, the baby should not be stimulated to breathe. 2. Although the heart rate is important, cardiac function is secondary to respiratory function. content/full/117/5/e1029) 4. The baby is kept in a head-down, supine position.

During a health maintenance visit at the pediatrician's office, the nurse notes that a breastfeeding baby has thrush. Which of the following actions should the nurse take? 1. Nothing because thrush is a benign problem. 2. Advise the mother to bottlefeed until the thrush is cured. 3. Obtain an order for antifungals for both mother and baby. 4. Assess for other evidence of immunosuppression.

3. Candida is a fungal infection, and it is important to treat both the mother's breasts and the baby's mouth to prevent the infection from being transmitted back and forth between the two. 1. Candida will infect both mother and baby. 2. Only under very special circumstances should a mother be advised not to breastfeed. And it is safe to breastfeed when the baby has thrush. 4. Although immunosuppressed patients often do develop thrush, that is an unlikely cause of thrush in this situation.

An infant in the neonatal nursery has low set ears, Simian creases, and slanted eyes. The nurse should monitor this infant carefully for which of the following signs/symptoms? 1. Blood-tinged urine. 2. Hemispheric paralysis. 3. Cardiac murmur. 4. Hemolytic jaundice.

3. Cardiac anomalies occur much more frequently in Down babies than in other babies. 1. This baby has Down syndrome. The genetic disease is not associated with bloodtinged urine. 2. Down babies are not at high risk for hemispheric paralysis. 4. Down babies are no more at risk for hemolytic jaundice than are other babies.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3. Cramping is an expected outcome

A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe since the vaccine is given by mouth.

3. Epinephrine should be available whenever vaccinations are administered in case the recipient should develop anaphylactic symptoms.

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT) even when the woman has a negative Homan's sign? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

3. Even with a negative Homan's sign, these findings—swelling, redness, and warmth—indicate presence of a DVT.

A bottlefeeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that further teaching is needed? 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby face down on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable.

3. In the first few weeks of life, it is important to burp babies frequently throughout feedings. Bottlefed babies often take in a great deal of air. Babies who burp only at the end of the feed often burp up large quantities of formula. Further teaching is needed.

A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions like she wants to bottlefeed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottlefeed.

3. It is a common belief among the women of many cultures, including Mexican, some Asian, and some Native Americans, that colostrum is bad for babies

A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

3. It is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales.

The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period, babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

3. It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile.

The nurse is developing a teaching plan for parents of an infant with a tetralogy of Fallot. Which of the following positions should parents be taught to place the infant during a "blue," or "tet," spell? 1. Supine. 2. Prone. 3. Knee-chest. 4. Semi-Fowler's.

3. Knee-chest.

A full-term baby's bilirubin level is 15 on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3. Lethargy is one of the most common early symptoms of hyperbilirubinemia. 1. Excessive crying is not a symptom of hyperbilirubinemia. 2. Babies often feed poorly when their bilirubin levels are elevated. 4. Hyperreflexia is seen with prolonged periods of markedly elevated serum bilirubin.

A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If they take their baby outside, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician. 4. They should notify their pediatrician when the umbilical cord falls off.

3. Liquid acetaminophen should be available in the home, but it should not be administered until the parent speaks to the pediatrician.

The nurse should expect to observe which behavior in a 3-week multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

3. Mothers who experience postpartum depression often do feel like failures. 1. Feelings of infanticide are not consistent with the diagnosis of postpartum depression. 2. Difficulty latching babies to the breast is an independent problem from postpartum depression. Some mothers with depression are successful breast feeders, while some mothers who do not experience depression have difficulty latching their babies to the breast

A woman, who has recently received Demerol (meperidine) 100 mg IM for labor pain, is about to deliver. Which of the following medications is highest priority for the nurse to prepare in case it must be administered to the baby following the delivery? 1. Oxytocin (Pitocin). 2. Xylocaine (Lidocaine). 3. Naloxone (Narcan). 4. Butorphanol (Stadol).

3. Narcan is an opiate antagonist. It may be administered to a depressed baby at delivery

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. Morphine. 2. Opium. 3. Narcan. 4. Phenobarbital.

3. Narcan is an opiate. If it were to be given to the neonate with neonatal abstinence syndrome, the baby would go into a traumatic withdrawal. Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy.

The nurse caring for an infant with a congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? 1. Hypertension, cyanosis, bradycardia. 2. Irritability, hypotension, palpitations. 3. Tachypnea, tachycardia, diaphoresis. 4. Angina, oliguria, dysrhythmias.

3. No matter whether a baby or an adult is developing CHF, the early signs that the nurse would note are tachypnea, tachycardia, and diaphoresis

Four newborns are in the neonatal nursery. Which of the babies should the nurse report to the neonatalogist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

3. Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic. 1. Meconium should pass within 24 hours of delivery. 2. This baby's glucose level is within normal limits. 4. A milky discharge—witch's milk—is normal. It results from the drop in maternal hormones in the neonatal system following delivery

feeding because, "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3. Normal postpartum behavior.

A baby is born with esophageal atresia and tracheoesophageal fistula. Which of the following complications of pregnancy would the nurse expect to note in the mother's history? 1. Preeclampsia. 2. Idiopathic thrombocytopenia. 3. Polyhydramnios. 4. Severe iron deficiency anemia.

3. Polyhydramnios is often seen in pregnancies complicated by a fetus with a digestive blockage. Babies swallow amniotic fluid in utero. When there is a blockage in the digestive system, they are unable to swallow the fluid. The fluid builds up in the uterus and polyhydramnios is noted.

Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3. Postdates babies are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates.

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate infant positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples. 1. Nipple shields should be used sparingly. Other interventions should be tried first. 2. Soap will deplete the breast of its natural lanolin. It is recommended that women wash their breasts with warm water only while breastfeeding

A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

3. Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed. 1. Hydrogen peroxide is not used when cleansing the circumcised penis. 2. Antifungals are not indicated in this situation. 4. Dry dressings are not applied to the circumcised penis. It is, however, usually recommended to liberally apply petroleum jelly to the site before diapering. The petroleum jelly may be applied directly to the penis via a sterile dressing or via a Vaseline-impregnated gauze.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. Hyperopia. 2. Gestational diabetes. 3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age

3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age 1. Hyperopia, another name for farsightedness, is unrelated to placental function. 2. If the mother had gestational diabetes, the nurse would expect the baby to be macrosomic, not to have IUGR. 3. Placental function is affected by the vasoconstrictive properties of many illicit drugs, as well as by cigarette smoke. 4. Placental function is diminished in women who have chronic hypertension. 5. Placental function has been found to be diminished in women of advanced maternal age.

A mother of a preterm baby is performing kangaroo care in the neonatal nursery. Which of the following responses would the nurse evaluate as a positive neonatal outcome? 1. Respiratory rate of 70. 2. Temperature of 97.0ºF. 3. Licking the mother's nipples. 4. Flaring of the baby's nares.

3. The baby is showing signs of interest in breastfeeding. This is a positive sign. 1. Respiratory rate of 70 is above normal. The rate should be between 30 and 60 breaths per minute. 2. Temperature of 97.0ºF is below normal. The temperature should be between 97.6ºF and 99ºF. 4. Nasal flaring is an indication of respiratory distress, which is abnormal.

A baby is born with a diaphragmatic hernia. Which of the following signs/symptoms would the nurse observe in the delivery room? 1. Projectile vomiting. 2. High-pitched crying. 3. Respiratory distress. 4. Fecal incontinence.

3. The baby will develop respiratory distress very shortly after delivery. Abdominal organs are displaced into the thoracic cavity when a baby is born with a diaphragmatic hernia.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3. The blood volume does drop precipitously during the early postpartum period. 1. The urinary output increases during the early postpartum period. 2. The blood pressure should remain stable during the postpartum. 4. The estrogen levels drop during the early postpartum period.

The nurse is discharging four Rh-negative clients from the maternity unit. The nurse knows that further teaching is needed when the client who had which of the following deliveries asks why she has not received her RhoGAM? 1. Abortion at 10 weeks' gestation. 2. Fetal demise at 24 weeks' gestation. 3. Birth of Rh-negative twins at 35 weeks' gestation. 4. Delivery of a 40-week-gestation Rh-positive baby

3. The client does not need a RhoGAM injection after the delivery of Rh negative twins. 1. The client should receive a RhoGAM injection after a spontaneous abortion. 2. The client should receive a RhoGAM injection after a fetal demise. 4. The client should receive a RhoGAM injection after birth of an Rh-positive baby

A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period? 1. Infection. 2. Bloody urine. 3. Heavy lochia. 4. Rectal abrasions.

3. The client should be monitored carefully for heavy lochia. Hemorrhage usually occurs early, secondary to cervical, vaginal, or perineal lacerations. Infection usually develops later in the postpartum period secondary to contamination of the uterine cavity during the application of the forceps

A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery while the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression

3. The client who has had the spinal anesthesia is much more likely to develop a postural headache than a client who had epidural anesthesia. 1. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing pruritus. 2. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing nausea. 4. Both the spinal anesthesia and the epidural anesthesia client are at high risk for developing respiratory depression.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3. The client will have a moderate lochial flow.

A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

3. The nurse should call a code first.

A 2-day postpartum mother, G2P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."

3. The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy.

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed at 11.0 gm/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 gm/dL; Hct 37%. 2. Hgb 11.0 gm/dL; Hct 33%. 3. Hgb 10.5 gm/dL; Hct 31%. 4. Hgb 9.0 gm/dL; Hct 27%.

3. The nurse would expect these values—a slight decrease in both hemoglobin and hematocrit values

A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

3. The nurse would recommend that the iron be taken with orange juice because ascorbic acid, which is in orange juice, promotes the absorption of iron into the body.

A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

3. The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse.

The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of preeclampsia.

3. The respiratory rate of 12 is well below normal. Respiratory rates average 20 rpm

A preterm infant has a patent ductus arteriosus (PDA). Which of the following explanations should the nurse give to the parents about the condition? 1. Hole has developed between the left and right ventricles. 2. Hypoxemia occurs as a result of the poor systemic circulation. 3. Oxygenated blood is reentering the pulmonary system. 4. Blood is shunting from the right side of the heart to the left.

3. There is a left to right shunt of blood with a patent ductus arteriosus (PDA) resulting in oxygenated blood reentering the pulmonary system.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

3. This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation.

A neonate is being admitted to the well-baby nursery. Which of the following findings should be reported to the neonatalogist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

3. Undescended testes—cryptorcidism— is an unexpected finding. It is one sign of prematurity

A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings must the nurse report to the primary health care provider? 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Telangiectatic nevi.

3. When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this. 1. Harlequin sign—deep red coloring over one side of the baby's body and pale coloration over the other side—is transient and normal. 2. Extension of the toes when the lateral aspect of the sole is stroked is the expected Babinski reflex until approximately 2 years of age. 4. Telangiectatic nevi, or stork bites, are pale pink spots often found on the eyelids and at the nape of the neck. They usually fade by age 2.

A baby is born with a meningomyelocele at L2. In assessing the baby, which of the following would the nurse expect to see? 1. Sensory loss in all four extremities. 2. Tuft of hair over the lumbosacral region. 3. Flaccid paralysis of the legs. 4. Positive Moro reflex.

3. With a defect at L2, the nurse would expect to see paralysis of the legs.

It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

4. Abductors usually choose newborns of their same race 1. Males are rarely newborn abductors. 2. Women who abduct neonates are often overweight. They rarely appear underweight. 3. Pro-life advocates have not been shown to be high risk for neonatal abduction.

A newly delivered mother states, "I have not had any alcohol since I decided to become pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best response by the nurse? 1. "I understand that being good for so many months can become very frustrating." 2. "Even if you bottlefeed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." 3. "Alcohol can be consumed at any time while you are breastfeeding." 4. "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."

4. Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consumption is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink before feeding again. If she decides to have more than one drink ,she can pump and dump her milk for a feeding or two.

A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus? 1. Abdominal striae. 2. Oliguria. 3. Omphalocele. 4. Absent bowel sounds

4. An absence of bowel sounds may indicate that a client has a paralytic ileus. One of the complications of surgery and/or anesthesia is a paralytic ileus, the cessation of intestinal peristalsis. The client should be given nothing by mouth. Among other interventions, a nasogastric tube is usually inserted and attached to low suction.

The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

4. Babies whose cheeks move in and out during feeds are attempting to use negative pressure to extract the milk from the breasts. This action is not an indicator of breastfeeding success.

A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4. Because of the heavy lochia, the nurse should notify the woman's health care provider.

The nurse is teaching a couple about the special health care needs of their newborn child with Down syndrome. The nurse knows that the teaching was successful when the parents state that the child will need which of the following? 1. Yearly three-hour glucose tolerance testing. 2. Immediate intervention during bleeding episodes. 3. A formula that is low in lactose and phenylalanine. 4. Prompt treatment of upper respiratory infections.

4. Because of the hypotonia of the respiratory accessory muscles, Down babies often need medical intervention when they have respiratory infections.

Which short-term goal is appropriate for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 3 to 4 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

4. By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period. 1. Breastfed babies usually regain their birth weights by about day 10. 2. Rarely do babies sleep through the night by 4 weeks of age. 3. By 1 week of age, breastfed babies should have 3 bright yellow stools in every 24- hour period, although some babies do stool more frequently.

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that more teaching is needed when the mother states that which of the following diseases is included in the screening test? 1. Hypothyroidism. 2. Sickle cell anemia. 3. Galactosemia. 4. Cerebral palsy.

4. Cerebral palsy (CP) is a disorder characterized by motor dysfunction resulting from a nonprogressive injury to brain tissue. The injury usually occurs during labor, delivery, or shortly after delivery. Physical examination is required to diagnose CP. Blood screening is not an appropriate means of diagnosis. 1. Congenital hypothyroidism is a malfunction of or complete absence of the thyroid gland that is present from birth. It is screened for in all 50 states. 2. Sickle cell disease is an autosomal recessive disease resulting in abnormally shaped red blood cells. It is screened for in all 50 states. 3. Galactosemia is an incurable autosomal recessive disease characterized by the absence of the enzyme required to metabolize galactose. It is screened for in all 50 states.

The nurse is providing discharge teaching to the parents of a baby born with a cleft lip and palate. Which of the following should be included in the teaching? 1. Correct technique for the administration of a gastrostomy feeding. 2. Need to watch for the appearance of blood-stained mucus from the nose. 3. Optimal position for burping after nasogastric feedings. 4. Need to give the baby sufficient time to rest during each feeding

4. Cleft lip and palate babies require additional time to rest as well as to suck and swallow when being fed. 1. It is not necessary to feed these babies via gastrostomy tubes. 2. Blood-stained mucus is not associated with cleft lip or palate. 3. It is not necessary to feed these babies via nasogastric tubes.

The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby care skills like diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills like pumping.

4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby. 1. Nourishment is a need of the client in the taking in phase. 2. Rest is a need of the client in the taking in phase. 3. Assistance with self-care is a need of the client in the taking in phase.

A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

4. If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted.

A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 25 mg/dL and after a feeding of mother's expressed breast milk is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatalogist of the abnormal glucose levels.

4. If the glucose level has not risen to normal as a result of the feeding, the nurse should notify the physician and anticipate that the doctor will order an intravenous of dextrose and water

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

4. Many mothers who consume approximately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding.

A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is critical at this time? 1. Bath to remove meconium-contaminated fluid from the skin. 2. Ophthalmic assessment to check for conjunctival irritation. 3. Rectal temperature to assess for septic hyperthermia. 4. Respiratory evaluation to monitor for respiratory distress.

4. Meconium aspiration syndrome (MAS) is a serious complication seen in postterm neonates who are exposed to meconium-stained fluid. Respiratory distress would indicate that the baby has likely developed MAS.

The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatalogist? 1. The eyes cross and uncross when they are open. 2. The ears are positioned in alignment with the inner and outer canthus of the eyes. 3. Axillae and femoral folds of the baby are covered with a white cheesy substance. 4. The nostrils flare whenever the baby inhales.

4. Nasal flaring is a symptom of respiratory distress

A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottlefed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottlefeed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

4. Once the reference has been consulted, the nurse will have factual information to relay to the physician—specifically that ampicillin is compatible with breastfeeding. A call to the doctor would then be appropriate

A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff.

4. One out of 4 women complains of painful and stiff joints after receiving the injection.

A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4. Pad saturation every 30 minutes.

A nurse hears a heart murmur on a full-term neonate in the well baby nursery. The baby's color is pink while at rest and while feeding. The baby most likely has which of the following cardiac defects? 1. Transposition of the great vessels. 2. Tetralogy of Fallot. 3. Pulmonic stenosis. 4. Patent ductus arteriosus.

4. Patent ductus arteriosus (PDA) is a very common cardiac defect in preterm babies. It is an acyanotic defect with a left to right shunt. Already oxygenated blood reenters the pulmonary system. 1. Transposition of the great vessels is a cyanotic defect that, if it stands alone, is incompatible with life. 2. Tetralogy of Fallot is a cyanotic defect characterized by four defects: VSD, pulmonic stenosis, overriding aorta, and right ventricular hypertrophy. 3. Pulmonic stenosis is characterized by a narrowed pulmonic valve. The blood, therefore, is restricted from entering the pulmonary artery and the lungs in order to be oxygenated.

A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

4. Prolonged supine posturing by babies can result in flattening of the backs of babies' heads (plagiocephaly). Being placed in the prone position while awake allows babies to practice gross motor skills like rolling over.

A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby

4. Provide discharge teaching to the mother of a 4-day-old baby It is the registered nurse's responsibility to provide discharge teaching to clients. Only the RN knows the scientific rationales as well as the knowledge of teaching-learning principles necessary to provide accurate information and answer questions appropriately.

A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills.

4. Providing instruction on baby care skills is a very important action for the nurse to perform. (Babies of mothers who are addicted to illicit drugs go through a withdrawal period and, because of the addiction, often have very disorganized behavior patterns. The nurse must provide guidance ) 1. This action is inappropriate. Breastfeeding is contraindicated when the mother uses illicit drugs. 2. This action is unnecessary. There is nothing in the scenario that implies that the client is having respiratory difficulties. 3. This action is inappropriate. Rather the nurse should encourage mother/baby interaction and provide the mother with parenting education.

A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised in order for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics asserts that circumcision is optional.

4. The AAP, although acknowledging that there are some advantages to circumcision, states that there is not enough evidence to suggest that all baby boys be circumcised.

When examining a nenonate in the well-baby nursery, the nurse notes that the sclerae of both of the baby's eyes is visible above the iris of the eyes. Which of the following assessments is highest priority for the nurse to make next? 1. Babinski and tonic neck reflexes. 2. Evaluation of bilateral eye coordination. 3. Blood type and Coombs' test results. 4. Circumferences of the head and chest.

4. The baby should be assessed for signs of hydrocephalus, especially a disparity between the circumferences of the neonatal head and the neonatal chest

On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. "Have you ever had anesthesia before?" 2. "Do you have any allergies?" 3. "Do you scar easily?" 4. "Are there many stairs in your home?"

4. The client has had major surgery. The client will need some assistance when she returns home, especially if she has a number of stairs to climb.

A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

4. The client is exhibiting inappropriate behavior when she yells at the baby for crying. The nurse must make additional assessments to determine whether there is any other evidence of abuse or neglect 1. Lochia serosa at 2 weeks' postpartum is unusual, but it does not put the client or her baby in imminent danger. 2. This client is exhibiting signs of postpartum depression. This is a problem that must be remedied, but it does not put the client or her baby in imminent danger. 3. The client's cracked nipples do need intervention, but they do not put the client or her baby in imminent danger.

The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

4. The client should seek care for a recent weight loss. This may be a symptom of full-blown AIDS 1. Breastfeeding is contraindicated when a mother is HIV positive. 2. It is recommended that HIV-positive clients use condoms for family planning. 3. It is unnecessary to take her temperature every morning. If she should develop a fever, she should seek medical assistance as soon as possible, however.

The nurse enters a Latin woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70ºF. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature since the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed.

4. The clothing should be removed and the mother should be educated about SIDS and about the correlation between overheating and SIDS.

The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? 1. Prepare epinephrine for administration. 2. Provide positive pressure oxygen. 3. Administer chest compressions. 4. Rub the back and feet of the baby.

4. The first interventions when a neonate fails to breathe include providing tactile stimulation.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.

Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatalogist to evaluate? 1. The neonate with a temperature of 97.9ºF and weight of 3000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with respirations of 72 and heart rate of 166.

4. The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottlefeed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. The nurse should discuss the action of oxytocin. 1. It is inappropriate to advise a breastfeeding mother to switch to the bottle unless there is a specific medical reason for her to do so. 2. Massaging the fundus will not relieve the client's discomfort. 3. An alternate position will not relieve the client's discomfort

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

4. The nurse would expect that the woman would have a low milk supply Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies

A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo. 2. Flat breast tissue. 3. Prominent clitoris. 4. Wrinkled skin.

4. The postterm baby does have dry, wrinkled, and often desquamating skin. The baby's dehydration is secondary to a placenta that progressively deteriorates after 40 weeks' gestation. 1. Abundant lanugo is seen in the preterm baby, not the postterm baby. 2. Absence of breast tissue is seen in the preterm baby, not the postterm baby 3. Prominent clitoris is seen in the preterm baby, not the postterm baby.

A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the health care practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.

4. The stools can be very caustic to the baby's delicate skin. The nurse should cleanse the area well and inspect the skin for any sign that the skin is breaking down. 1. The stools are green from the increase in excreted bilirubin. 2. There is no need to inform the health care practitioner. Green stools are an expected finding. 3. Although green stools can be seen with diarrheal illnesses, in this situation, the green stools are expected and not related to an infectious state.

The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6°F, 82, 18; fundus firm at umbilicus; moderate lochia; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.

4. This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding infant care as well as self-care.

A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able exclusively to breastfeed.

4. This information is true. Women who have had augmentation surgery usually are able to breastfeed exclusively. Because breast implants are usually inserted behind the breast tissue, the mammary ducts are rarely affected.

A client, G1P1001, 1-hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4. This is the appropriate action by the nurse. 1. The client should ambulate. There is nothing in the scenario indicating that the client must use a bedpan. 2. It is likely that the client needs to urinate. 3. In-dwelling catheters are rarely inserted for vaginal deliveries.

The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "Oh, I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

4. This response is correct. It is unsafe to place anything in the vagina before involution is complete.

A client, G1P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4. This response shows that the nurse has an understanding of the client's feelings.

The nurse is caring for a client, G3P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make? 1. "Thank goodness. It could have been untreatable." 2. "I'm so happy that you have other children who are healthy." 3. "These things happen. They are the will of God." 4. "It is appropriate for you to cry at a time like this."

4. This statement is appropriate. Clients may need help or permission to express their grief. 1. This statement is inappropriate. Any defect is devastating for the parents to accept. 2. This statement is inappropriate. This child is affected. That is all that matters. 3. This statement is inappropriate. The nurse must not impose his or her beliefs on the couple.

A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the nurse encourage the client to perform? 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day.

4. Wear a supportive bra 24 hours a day.

A baby in the NICU, who is exhibiting signs of congestive heart failure from an atrioventricular canal defect, is receiving a diuretic. In the plan of care, the nurse should include that the desired outcome for the child will be which of the following? 1. Loss of body weight. 2. Drop in serum sodium level. 3. Rise in urine specific gravity. 4. Increase in blood pressure.

1. A diuretic will increase urinary output which in turn will lead to weight loss. 2. A drop in sodium is not a goal of diuretic therapy. 3. Rather than an increase in specific gravity, the nurse would expect to see a drop in specific gravity. 4. An increase in blood pressure is not a goal of diuretic therapy

A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus

1. A moderate lochia flow would indicate that the action was successful. 2. Decreased pain is not an expected outcome of uterine massage for uterine atony. 3. A stable postpartum blood pressure is not directly related to the action of uterine massage. 4. The expected outcome would be that the uterus is contracted at or below the umbilicus.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1. ABO incompatibility can arise when the mother is type O and the baby is either type A or type B.

The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? 1. Wash hands well before picking up the baby. 2. Refrain from having visitors for the first month. 3. Wear a mask to prevent transmission of a cold. 4. Sterilize the breast pump supplies for the first month.

1. Although this baby is being breastfed, he or she is still susceptible to illness. The best way to prevent transmission of pathogens is to wash hands carefully before touching the baby. 2. Visitors, too, should wash hands before touching the baby, but it is unnecessary to isolate the baby from them. 3. The best way to prevent the transmission of a cold is to wash hands. Also, this baby is receiving protective antibodies through the breast milk. Masks are not necessary. 4. Sterilization is not necessary. All washable pieces of the equipment should be washed thoroughly in dish detergent and water and rinsed well. The dishwashersafe pieces could be cleansed in the dishwasher

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1. Apply an ice pack to the perineum. _________________________________________ 2. The sitz bath is an appropriate intervention beginning on the second postpartum day, not 2 hours after delivery. Sitz baths are usually performed 2 to 3 times a day

During neonatal cardiopulmonary resuscitation, which of the following actions should be performed? 1. Provide assisted ventilation at 40 to 60 breaths per minute. 2. Begin chest compressions when heart rate is 0 to 20 beats per minute. 3. Compress the chest using the three-finger technique. 4. Administer compressions and breaths in a 5 to 1 ratio.

1. Assisted ventilations should be administered at a rate of 40 to 60 per minute. 2. Chest compressions should be begun when the heart rate is below 60 beats per minute. 3. The chest should be compressed using either the "2-thumb" or the "2-finger" techniques. 4. The compressions and ventilations should be administered in a 3 to 1 ratio.

A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatalogist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

1. Babies are awake and alert for approximately 30 minutes to 1 hour immediately after birth. This is the perfect time for the parents to begin to bond with their babies. 2. There is no reason to notify the neonatalogist. 3. This is a full-term baby. There is no need to perform a gestational age assessment. 4. Warmth can be maintained preferably by placing the baby skin-to-skin with the mother or, if required, by swaddling the baby in one or more blankets

The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

1. Babies learn to speak by imitating the speech of others in their environment. If they are hearing impaired, there is a likelihood of delayed speech development.

A full-term neonate in the NICU has been diagnosed with congestive heart failure secondary to a cyanotic heart defect. Which of the following activities is most likely to result in a cyanotic episode? 1. Feeding. 2. Sleeping in the supine position. 3. Rocking in an infant swing. 4. Swaddling.

1. Babies who have cardiac defects frequently feed poorly. And when they do feed, they frequently become cyanotic.

The neonatalogist assesses a newborn for Hirschsprung's disease after the baby exhibited which of the following signs/symptoms? 1. Passed meconium at 50 hours of age. 2. Apical heart rate of 200 beats per minute. 3. Maculopapular rash. 4. Asymmetrical leg folds.

1. Babies who have delayed meconium excretion may have Hirshsprung's disease. Hirshsprung's disease is defined as a congenital lack of parasympathetic innervation to the distal colon.

A neonate that is admitted to the neonatal nursery is noted to have a 2-vessel cord. The nurse notifies the neonatalogist to get an order for which of the following assessments? 1. Renal function tests. 2. Echocardiogram. 3. Glucose tolerance test. 4. Electroencephalogram.

1. Babies with 2-vessel cords are at high risk for renal defects.

Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottlefeed her child? 1. The woman with a neoplasm requiring chemotherapy. 2. The woman with cholecystitis requiring surgery. 3. The woman with a concussion. 4. The woman with thrombosis.

1. Breastfeeding is contraindicated when a woman is receiving chemotherapy

A mother, who gave birth 5 minutes ago, states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? 1. Assist the woman to breastfeed. 2. Assess the baby's blood pressures. 3. Administer the ophthalmic prophylaxis. 4. Take the baby's rectal temperature.

1. Breastfeeding should be instituted as soon as possible to promote milk production, stability of the baby's glucose levels, and meconium excretion, as well as to stabilize the baby's temperature through skin-to-skin contact.

A 6-month-old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. 1. Bronchopulmonary dysplasia. 2. Cerebral palsy. 3. Retinopathy. 4. Hypothyroidism. 5. Seizure disorders.

1. Bronchopulmonary dysplasia. 2. Cerebral palsy. 3. Retinopathy. 5. Seizure disorders. 1. Bronchopulmonary dysplasia often is a consequence of the respiratory therapy that preemies receive in the NICU. 2. Cerebral palsy results from a hypoxic insult that likely occurred as a result of the baby's prematurity. 3. Retinopathy of the premature is a disease resulting from the immaturity of the vascular system of the eye. 4. Hypothyroidism is one of the diseases assessed for in the neonatal screen. It is very unlikely that this problem resulted from the baby's stay in the NICU. 5. Seizure disorders can result either from a hypoxic insult to the brain or from a ventricular bleed. Both of these conditions likely occurred as a result of the prematurity.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1. Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement. 4. It is unnecessary to assess this client's temperature and pulse rate. This client is engorged; she is not infected.

A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage.

1. Clients should be warned about consuming alcohol when taking Paxil. 2. Grapefruit is not contraindicated for clients who have been prescribed Paxil. 3. Milk is not contraindicated for clients who have been prescribed Paxil. 4. Cabbage is not contraindicated for clients who have been prescribed Paxil.

The nurse assessed four newborns admitted to the neonatal nursery and called the neonatalogist for a consult on the baby who exhibited which of the following? 1. Excessive amounts of frothy saliva from the mouth. 2. Blood-tinged discharge from the vaginal canal. 3. Secretion of a milk-like substance from both breasts. 4. Heart rate that sped during inhalation and slowed with exhalation.

1. Excessive amounts of frothy saliva may indicate that the child has esophageal atresia. 2. Blood-tinged vaginal discharge is a normal finding in female neonates. 3. Milk-like secretion from the breast is a normal finding in neonates. It is normal for a baby's heart rate to speed slightly during inhalation and slow slightly during exhalation.

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess this baby for which of the following? 1. Poor suck reflex. 2. Ambiguous genitalia. 3. Webbed neck. 4. Absent Moro reflex.

1. FAS babies usually have a very weak suck reflex.

A neonate is found to have choanal atresia on admission to the nursery. Which of the following physiological actions will be hampered by this diagnosis? 1. Feeding. 2. Digestion. 3. Immune response. 4. Glomerular filtration.

1. Feeding. Choanal atresia, a congenital narrowing of the nasal passages, seriously affects babies' ability to feed.

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1. Fundal assessment is the priority nursing action

A baby, admitted to the nursery, was diagnosed with galactosemia from an amniocentesis. Which of the following actions must the nurse take? 1. Feed the baby a specialty formula. 2. Monitor the baby for central cyanosis. 3. Do hemoccult testing on every stool. 4. Monitor baby for signs of abdominal pain.

1. Galactosemia is one of the few diseases that is a contraindication for the intake of breast milk or any milkbased formula. ( Galactosemia, an autosomal recessive disease, is characterized by an inability to digest galactose, a by-product of lactose digestion) 2. Galactosemia is a metabolic defect. There is no cardiovascular component. 3. Diarrhea and other malabsorption symptoms will be seen over time, but bloody stools would not be seen in the nursery. 4. Although vomiting and diarrhea do occur, the baby is unlikely to have abdominal pains.

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply. 1. Grasp the baby's thighs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct the baby's thighs. 3. Palpate the trochanter to sense changes during hip rotation. 4. Place the baby in a prone position. 5. Flex the baby's hips and knees at 90º angles.

1. Grasp the baby's thighs with the thumbs on the inner thighs and forefingers on the outer thighs. 3. Palpate the trochanter to sense changes during hip rotation. 5. Flex the baby's hips and knees at 90º angles. 1. With the baby placed flat on its back, the practitioner grasps the baby's thighs using his or her thumbs and index fingers. 2. When assessing for Ortolani sign, the baby's thighs are abducted rather than adducted. 3. With the baby's hips and knees at 90º angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum. 4. The baby is placed flat on its back. 5. Flex the baby's hips and knees at 90º angles.

Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for hypothermia? 1. The baby whose mother cultured positive for group B strep during her third trimester. 2. The baby whose mother had gestational diabetes. 3. The baby whose mother was hospitalized for 3 months with complete placenta previa. 4. The baby whose mother previously had a stillbirth.

1. Group B streptococcus causes severe infections in the newborn. A sign of neonatal sepsis is hypothermia. _______________________________________ 2. Babies whose mothers had gestational diabetes (GDM) should be carefully monitored for hypoglycemia rather than for hypothermia.

A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. For which of the following client outcomes should the nurse plan to monitor the baby? 1. 6 saturated diapers in 24 hours. 2. Breastfeeds 6 times in 24 hours. 3. 12% weight loss since birth. 4. Apical heart rate of 176 bpm.

1. Healthy, hydrated neonates saturate their diapers a minimum of 6 times in 24 hours. 2. In order to consume enough fluid and nutrients for growth and hydration, babies should breastfeed at least 8 times in 24 hours. 3. A weight loss of over 10% is indicative of dehydration. 4. Tachycardia can indicate dehydration.

A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? 1. Hyperthermia, vomiting, and diarrhea. 2. Hypotension and respiratory collapse. 3. Anasarca and fluid volume overload. 4. Palpitations, anxiety, and insomnia.

1. Hyperthermia, vomiting, and diarrhea. Hemabate can cause nausea, vomiting, diarrhea, and hyperthermia

A baby was just born to a mother who had positive vaginal cultures for group B streptococcus. The mother was admitted to the labor room 2 hours before the birth. For which of the following should the nursery nurse closely observe this baby? 1. Hypothermia. 2. Mottling. 3. Omphalocele. 4. Stomatitis.

1. Hypothermia in a neonate may be indicative of sepsis.

To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7ºF. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

1. Hypothermia in the neonate is defined as a temperature below 97.7ºF. Cold stress syndrome may develop if the baby's temperature is below that level. 2. A healthy neonate does not need supplemental feedings. And if supplements are needed, they should be either formula or breast milk. 3. There is no indication in the stem that glucose assessments are needed for this baby. 4. Babies should be breastfed every 2 to 3 hours. Feedings every 4 hours are not frequent enough.

A nurse is advising a couple of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? Select all that apply. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4ºF.

1. If the baby repeatedly refuses to feed. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4ºF. 1. Babies do not starve themselves. If a baby refuses to eat, it may mean that the baby is seriously ill. For example, babies with cardiac defects often refuse to eat. 2. Newborns normally breathe irregularly. Apnea spells of 10 seconds or less are normal. 3. Newborns do not tear when they cry. If a baby does tear, he or she may have a blocked lacrimal duct. 4. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. 5. A temperature above 100.4ºF is a febrile state for a newborn and the pediatrician should be notified.

A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every 5th suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch. (This client is complaining of engorgement. The baby is having difficulty latching because the breast is inflamed, making the nipple tense and short. ) 2. If the baby is latched well, he should swallow after every suck. 3. The nurse would expect the baby to transfer 60 mL or more at the feeding. 4. The mother should not squeeze her nipple. The area behind the areola should be gently compressed.

Monochorionic twins, whose gestation was complicated by twin-to-twin transfusion, are admitted to the neonatal intensive care unit. Which of the following characteristic findings would the nurse expect to see in the smaller twin? 1. Pallor 2. Jaundice. 3. Opisthotonus. 4. Hydrocephalus.

1. In twin-to-twin transfusion, the smaller twin has "donated" part of his or her blood supply to the larger twin. 2. The smaller twin is hypovolemic so the likelihood of jaundice is small. 3. Opisthotonus is defined as a full-body spastic posture. This is unrelated to twinto-twin transfusion. 4. Hydrocephalus is unrelated to twin-totwin transfusion.

The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatalogist? 1. Intracostal retractions. 2. Caput succedaneum. 3. Epstein's pearls. 4. Harlequin sign.

1. Intracostal retractions are a sign of respiratory distress

A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 5. Document the time the infusion begins. 1. The nurse must check the client's blood type. 2. The nurse must check the client's name by checking the bracelet and asking the client her name. 3. The nurse must compare the client's blood type with the blood type on the infusion bag. 4. The nurse must obtain an infusion of normal saline, not dextrose and water. 5. The time the infusion begins and ends must be documented.

A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine (methylergonovine). 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate.

1. Methergine is contraindicated for this client. Methergine is an oxytoxic agent. It acts directly on the myofibrils of the uterus. Secondarily, it also contracts the muscles of the vascular tree. As a result, clients' blood pressures tend to elevate when they receive this medication

A woman is visiting the NICU to see her 26-week-gestation baby for the first time. Which of the following methods would the nurse expect the mother to use when first making physical contact with her baby? 1. Fingertip touch. 2. Palmar touch. 3. Kangaroo hold. 4. Cradle hold.

1. Most mothers, even those of full-term babies, usually use finger-tip touch during their first physical contact with their babies. 2. Palmar touch usually follows fingertip touch. 3. Kangaroo hold is used in NICUs as a means of facilitating parent-infant bonding as well as promoting growth and development of the neonate. 4. Cradle hold is the classic hold of a mother with her baby. This hold follows other touch contact.

A macrosomic baby in the nursery is suspected of having a fractured clavicle from a traumatic delivery. Which of the following signs/symptoms would the nurse expect to see? Select all that apply. 1. Pain with movement. 2. Hard lump at the fracture site. 3. Malpositioning of the arm. 4. Asymmetrical Moro reflex. 5. Marked localized ecchymosis

1. Pain with movement. 2. Hard lump at the fracture site. 3. Malpositioning of the arm. 4. Asymmetrical Moro reflex. 1. The baby will complain of pain at the site. 2. If not in the immediate period after the injury, within a few days there will be a palpable lump on the bone at the site of the break. 3. Because of the break, the baby is likely to position the arm in an atypical posture. 4. Because of the injury to the bone, the baby is unable to respond with symmetrical arm movements. 5. It is very rare to see ecchymosis at the site of the break.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. 1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 5. Assess for anal fissures daily.

1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 1. Babies with necrotizing enterocolitis (NEC) have blood in their stools. 2. The abdominal girth measurements of babies with NEC increase. 3. When babies have NEC, they have increasingly larger undigested gastric contents after feeds. 4. The neonates' bowel sounds are diminished with NEC. 5. The presence of anal fissures is unrelated to NEC.

Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

1. Red blood cells in the cephalhematoma will have to be broken down and excreted. The byproduct of the destruction—bilirubin—increases the baby's risk for physiological jaundice. 2. A caput is merely a collection of edematous fluid. There is no relation between the presence of a caput and jaundice. 3. Harlequin coloration is related to the dilation of blood vessels on one side of the baby's body. There is no relation between the presence of harlequin coloring and jaundice. 4. Mongolian spots are hyperpigmented areas primarily seen on the buttocks. There is no relation between the presence of mongolian spots and jaundice.

A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. Hourly grip strengths performed with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage 2. Kernig's assessment is performed when checking for nuchal rigidity in a client with meningitis. 3. Pupillary responses are performed when a client has had a head injury or is not responsive. 4. Apical heart rate checks are performed when a client has a cardiac disease or is receiving digoxin.

A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically.

1. Showing signs of hunger and frustration describes the active alert or active awake state. 2. Starting to whimper and cry describes the crying behavioral state. 3. This describes the quiet alert state; sometimes called wide-awake state. 4. Sleeping and breathing regularly describe deep or quiet sleep

During a postpartum assessment, it is noted that a G1P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1. Sitz baths do have a soothing affect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids. 3. Oxytocin will have no affect on the hemorrhoids. 4. It is impossible to tell whether or not the hemorrhoids will change with subsequent pregnancies.

A breastfeeding mother refuses to place her unclothed baby face down on her chest because, "Babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

1. Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures. _________________________________ 2. Prone positioning, not supine, is contraindicated when babies are not being supervised. A baby being held skin-toskin on the mother's chest, however, is being supervised.

A mother tells the nurse that, because of family history, she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

1. Small, frequent feedings. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free. 1. Small, frequent feedings reduce the symptoms of colic in some babies. 2. The prone sleep position is not recommended for babies under 1 year of age. 3. Some babies' symptoms have decreased when they were tightly swaddled. 4. This is called the colic hold. The position does help to soothe some colicky neonates. 5. Babies who live in an environment where adults smoke have a higher incidence of colic than babies who live in a smoke-free environment.

A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

1. Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth. 2. The bowel sounds should be normal. 3. The Moro reflex should be normal. 4. Babies in the LMA position are not at high risk for developmental dysplasia of the hip. Breech babies are high risk for DDH.

A client is receiving a blood transfusion after the delivery of a placenta acreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion? 1. "My lower back hurts all of a sudden." 2. "My hands feel so cold." 3. "I feel like my heart is beating fast." 4. "I feel like I need to have a bowel movement."

1. Sudden lower back pain is a sign of a transfusion reaction If the client is receiving the wrong type blood or is allergic to the blood, she will develop flank or kidney pain.

A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 4. Ask the couple whether or not they would like to hold the baby. 1. This is an appropriate action. The baby should be handled with respect. 2. This is an appropriate action. Funerals help clients to achieve closure and to provide others with a means of acknowledging the baby's death. 3. This is inappropriate. The couple must grieve the loss of this child. 4. This is an appropriate action. Although there are some clients who will decline to hold their babies, the action is very important for those who accept the opportunity. 5. This action is inappropriate. Stating that the loss of a baby is for the best is very demeaning and unfeeling.

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatalogist of the significant weight loss. 3. Advise the mother to bottlefeed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

1. The baby has lost less than 4% of its birth weight. The normal weight loss for babies is 5% to 10%.

A baby is born with a suspected coarctation of the aorta. Which of the following assessments should be done by the nurse? 1. Check blood pressures in all four limbs. 2. Palpate the anterior fontanel for bulging. 3. Assess hematocrit and hemoglobin values. 4. Monitor for harlequin color changes.

1. The blood pressures in all four quadrants should be assessed. 2. A bulging fontanel, not coarctation of the aorta, is indicative of hydrocephalus. 3. At delivery, the hematocrit and hemoglobin will likely be the same as in a healthy baby. 4. Harlequin coloration is a normal finding.

A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

1. The client should be assessed by her health care practitioner. Because the perineum is edematous, the lochial flow is normal, and the pain level is well above that expected, the nurse should suspect that the client has developed a hematoma. The client should be assessed by her health care provider 2. The client may need a sitz bath, but should be assessed first. 3. It is unlikely that this client has a hidden laceration since her lochial flow is normal. 4. The client may benefit from a narcotic, but should be assessed first.

The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

1. The client with a placenta accreta is high risk for a large blood loss A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining.

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. The client would be expected to complain of pain A hematoma is a collection of blood under the skin. Although hematomas are usually simple bruises, large collections of blood can occur. Because the blood is trapped under the skin, the most common symptom is pain from the blood pressing on the pain sensors.

A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? 1. Compare mother's and baby's identification bracelets. 2. Help the mother into a comfortable position. 3. Teach the mother about a proper breast latch. 4. Tickle the baby's lips with the mother's nipple

1. The first action the nurse should ever perform is to make sure that the correct baby is being given to the correct mother. LOL

The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh positive.

1. The goal of the injection of RhoGAM is to inhibit the mother's immune response. As a result, there will be no antigen in the mother's body to stimulate her mast cells to have an active antibody response. In essence, therefore, RhoGAM is injected to inhibit the client's immune response. 2. Immune globulin is composed of antibodies. When a client receives RhoGAM, she receives passive antibodies to inhibit her immune response. 3. Passive antibodies cannot prevent the migration of fetal cells throughout the mother's bloodstream. 4. A client's blood type is determined by her DNA. R

The parents of a baby born with bilateral talipes equinovarus ask the nurse what medical care the baby will likely need. Which of the following should the nurse tell the parents? 1. Need a series of leg casts until the correction is accomplished. 2. Have a Harrington rod inserted when the child is about three years old. 3. Have a Pavlik harness fitted before discharge from the nursery. 4. Need to wear braces on both legs until the child begins to walk.

1. The initial treatment plan for clubfoot usually includes a series of casts that slowly move the foot into proper alignment. 2. Harrington rod insertion has been used to treat scoliosis, not talipes equinovarus. 3. Pavlik harness is a therapy for a baby with DDH. 4. Long-term bracing is not a common therapy for clubfoot.

A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. 5 babies less than 28 days old per 1000 live births died. 2. 5 babies less than 1 year old per 1000 live births died. 3. 5 babies less than 28 days old per 100,000 births died. 4. 5 babies less than 1 year old per 100,000 births died.

1. The neonatal period is defined as the first 28 days of life. The neonatal mortality rate is defined as neonatal deaths per 1000 live births. Therefore, 5 babies less than 28 days old per 1000 live births died.

A nurse administered RhoGAM to a client whose blood type is A + (positive). Which of the following responses would the nurse expect to see? 1. Fever, flank pain, elevated bilirubin. 2. Induration and redness at the injection site. 3. Mild pain and swelling at the injection site. 4. Polycythemia, headache, hives.

1. The nurse would expect to see fever, flank pain, and elevated bilirubin levels. When RhoGAM is administered to an Rh! (positive) client, antibodies against the client's red blood cells are being injected into her body. A hemolytic response similar to one seen when a client receives the wrong type of blood will develop.

A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? 1. Urine drug toxicology test. 2. Biophysical profile test. 3. Chest and abdominal ultrasound evaluations. 4. Oxygen saturation and blood gas assessments

1. The symptoms are characteristic of neonatal abstinence syndrome. A urine toxicology would provide evidence of drug exposure. 2. Biophysical profiles are done during pregnancy to assess the well-being of the fetus. 3. There is no indication from the question that this child has any chest or abdominal abnormalities. 4. This child is not exhibiting signs of respiratory distress

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

1. The woman should never be left alone with her infant. 2. The statement is untrue. There is no set time frame for the resolution of the symptoms of postpartum psychosis. 3. Clinical response to medications is usually quite good. 4. The client's vital signs need not be assessed frequently

A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No, there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." 4. "Yes, spices from hot and spicy foods get into the milk and can bother your baby."

1. There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis

A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatalogist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

1. This baby has only lost 3.7% of his or her birth weight—100/2678 x 100% = 3.7%. This is below the accepted weight loss of 5% to 10%.

A 42-week-gestation baby, 2400 grams, whose mother had no prenatal care, is admitted into the NICU. The neonatalogist orders blood work. Which of the following laboratory findings would the nurse expect to see? 1. Blood glucose 30 mg/dL. 2. Leukocyte count 1000 cells/mm3. 3. Hematocrit 30%. 4. Serum pH 7.8.

1. This baby is small-for-gestational age. Full-term babies (40 weeks' gestation) should weigh between 2500 and 4000 grams. It is very likely that this baby used up his glycogen stores in utero because of an aging placenta. An aging placenta is unable to deliver sufficient nutrients to the fetus. As a result the fetus must use its glycogen stores to sustain life and, therefore, is high risk for hypoglycemia after birth.

A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. This client is high risk for uterine atony. (failure of contraction)

A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

1. This is true. The baby must be at the level of the breast in order to feed effectively. 2. In the cross-cradle position, the baby's head is in the mother's hand. 3. The baby should be positioned facing the mother—"tummy-to-tummy." 4. The baby should be brought to the mother. The mother should not move her body to the baby.

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. This output is below the accepted minimum for 8 hours. The output in the scenario is equal to 25 cc/hr. This is well below the accepted output of 30 cc/hr

The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman's care? 1. "Would you like me to order a vegetarian clear liquid diet for you?" 2. "Is there anything special you will need for your Sabbath on Sunday?" 3. "Would you like to telephone your clergy to set up a date for the baptism?" 4. "Will a rabbi be performing the circumcision on your baby?"

1. This question is appropriate. Seventh Day Adventists usually follow vegetarian diets. 2. This question is inappropriate. The Seventh Day Adventist Sabbath is on Saturday, not on Sunday. 3. This question is inappropriate. Baptism in the Seventh Day Adventist tradition is performed after the child reaches the age of accountability. 4. This question is inappropriate. Rabbis are the leaders of people of the Jewish faith. And mohels, who are not necessarily rabbis, perform ritual Jewish circumcisions.

A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

1. This response is correct. Reassuring the client is appropriate 2. It is unlikely that the client has a urinary tract infection. 3. The urine will be blood-tinged from the lochia. 4. This question is unnecessary. It is unlikely that the client has a urinary tract infection.

The nurse is caring for a baby diagnosed with developmental dysplasia of the hip (DDH). Which of the following therapeutic interventions should the nurse expect to perform? 1. Place the baby's legs in abduction. 2. External rotation of the baby's hips. 3. Assist with bilateral leg casting. 4. Monitor pedal pulses bilaterally.

1. To treat developmental dysplasia of the hip, babies' legs are maintained in a state of abduction. 2. External rotation of the hips is part of Ortolani test, which is a screening test for DDH. This action is not therapeutic. 3. Casting is only done in cases where splinting is ineffective. 4. There is no need to assess pedal pulses because they are unaffected in babies with DDH.

A mother is told that she should bottlefeed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis. 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1. Untreated, active tuberculosis. 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 1. A mother with active untreated TB should be separated from her baby until the mother has been on antibiotic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to baby through an alternate feeding method. 2. Being hepatitis B surface antigen positive (HBSag") is not a contraindication to breastfeeding. 3. Mothers who are HIV positive are advised not to breastfeed because there is an increased risk of transmission of the virus to the infant. 4. Acute bacterial infections, such as chorioamnionitis, are not contraindications to breastfeeding unless the medication given to the mother is contraindicated. There are, however, very few antibiotics that are incompatible with breastfeeding. 5. It is recommended that a mother with mastitis continue to breastfeed. She must keep draining her breasts of milk to prevent the development of a breast abscess. Again, only antibiotics compatible with breastfeeding should be administered.

A baby exhibits weak rooting and sucking reflexes. Which of the following nursing diagnoses would be appropriate? 1. Risk for deficient fluid volume. 2. Activity intolerance. 3. Risk for aspiration. 4. Feeding self-care deficit.

1. When a baby roots and sucks poorly, the baby is unable to transfer milk effectively. Since milk intake is the baby's source of fluid, the baby is high risk for fluid volume deficit. 2. Although a baby exhibiting fluid volume deficit may become activity intolerant, this is not the best answer. 3. Even when babies have poor rooting and sucking reflexes, they do not necessarily have poor gagging reflexes. 4. Babies are incapable of self-care.

The nursing management of a neonate with physiological jaundice should be directed toward which client care goal? 1. The baby shows no signs of kernicterus. 2. The baby does not develop erythroblastosis fetalis. 3. The baby has a bilirubin of 16 mg/dL on the day of discharge. 4. The baby spends at least 20 hours per day under phototherapy.

1. When bilirubin levels elevate to toxic levels, babies can develop kernicterus. 2. Erythroblastosis fetalis is a syndrome resulting from the antigen-antibody reaction related to maternal-fetal blood incompatibility. 3. This bilirubin level is above the level most neonatalogists consider acceptable for discharge. 4. Phototherapy is ordered when hyperbilirubinemia is present or when the development of hemolytic jaundice is very likely.

A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome. _________________________________________ 2. The first Apgar score is not done until 60 seconds after delivery. The wet blankets should have been removed from the baby well before that time.

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights on for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

1. When phototherapy is administered, the baby's eyes must be protected from the light source.

One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2. An important goal is that the woman's WBC will remain stable. 3. An important goal is that the woman's temperature will remain normal. 4. An important goal is that the woman's lochia will smell normal. 1. Although clients should drink fluids, this is not a goal related to the identified nursing diagnosis. 5. Sitz baths are not given to prevent infections. They do help to soothe the pain and/or the inflammation associated with episiotomies and hemorrhoids.

The nurse assessed four newborns in the neonatal nursery. The nurse called the neonatalogist for a cardiology consult on the baby who exhibited which of the following signs/symptoms? 1. Setting sun sign. 2. Anasarca. 3. Flaccid extremities. 4. Polydactyly.

2. Anasarca refers to overall, systemic edema. It is seen is severe cardiovascular disease. A cardiac consult would be appropriate for this baby as would, perhaps, a renal consult 1. Setting sun sign is a symptom of hydrocephalus. It is not a symptom of cardiac disease.. 3. A baby with flaccid extremities is exhibiting a neurological or musculoskeletal problem, not a cardiac problem. 4. A baby with polydactyly has more than 5 digits on the hands or feet. The finding has nothing to do with cardiac problems.

A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

2. Babies do not shiver. Rather, to produce heat they utilize chemical thermogenesis, also called nonshivering thermogenesis. BAT is metabolized during hypothermic episodes to maintain body temperature. Unfortunately, this can lead to metabolic acidosis. 1. Melanin production is not related to the presence of BAT. 3. BAT is unrelated to injury prevention. 4. Sufficient calories for growth are provided from breast milk or formula.

A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

2. Babies who are tongue-tied—that is have a tight frenulum—have difficulty extending their tongues while breastfeeding. The mothers' nipples often become damaged as a result.

A baby has just been born to a type 1 diabetic mother with retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? 1. Hyperalbuminemia. 2. Polycythemia. 3. Hypercalcemia. 4. Hypoinsulinemia.

2. Because the placenta is likely to be functioning less than optimally, it is highly likely that the baby will be polycythemic. The increase in red blood cells would improve the baby's oxygenation in utero 1. The baby's serum protein levels should be normal. 3. Rather than hypercalcemia, the nurse would expect to see hypocalcemia. 4. Rather than hypoinsulinemia, if the maternal glucose levels are higher than normal, the nurse would expect to see hyperinsulinemia in the neonate.

Which of the following statements is true about breastfeeding mothers as compared to bottlefeeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life

A woman whose 32-week-gestation neonate is to begin oral feedings is expressing breast milk (EBM) for the baby. The neonatalogist is recommending that fortifier be added to the milk because which of the following needs of the baby are not met by EBM? 1. Need for iron and zinc. 2. Need for calcium and phosphorus. 3. Need for protein and fat. 4. Need for sodium and potassium.

2. Calcium and phosphorus in EBM are in quantities that are less than body requirements for the very low birth weight baby. Therefore, a fortifier may need to be added to the EBM.

A baby has been admitted to the neonatal intensive care unit with a diagnosis of symmetrical intrauterine growth restriction. Which of the following pregnancy complications would be consistent with this diagnosis? 1. Severe preeclampsia. 2. Chromosomal defect. 3. Infarcts in an aging placenta. 4. Premature rupture of the membranes

2. Chromosomal abnormalities are associated with symmetrical IUGR. 1. Severe preeclampsia is associated with asymmetrical IUGR. 3. An aging placenta is associated with asymmetrical IUGR. 4. PPROM is associated with asymmetrical IUGR

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with a povidone-iodine solution after toileting.

2. Clients should be advised to change their pads at each voiding.

A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? 1. G1P0000, delivery at 29 weeks' gestation. 2. G2P1001, prolonged first stage of labor. 3. G2P0010, delivery by cesarean section. 4. G3P0200, delivery of 2200-gram neonate.

2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). 1. Preterm labor clients are not especially at high risk for postpartum hemorrhage. 3. Cesarean section clients are not especially at high risk for PPH. 4. Clients who deliver small babies are not especially at high risk for PPH.

The birth of a baby, weight 4500 grams, was complicated by shoulder dystocia. Which of the following neonatal complications should the nursery nurse observe for? 1. Leg deformities. 2. Brachial palsy. 3. Fractured radius. 4. Buccal abrasions.

2. During a difficult delivery with shoulder dystocia, the brachial nerve can become stretched and may even be severed. The nurse should, therefore, observe the baby for signs of palsy.

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatalogist as soon as possible? 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen.

2. Expiratory grunting is an indication of respiratory distress 1. Pseudomenses is a normal finding in a 1-day-old female. 3. This is a description of the harlequin sign, a normal neonatal finding. 4. Neonates are often mottled when chilled. Unless other signs or symptoms are present, it is a normal finding.

It is time for a baby, who is in the drowsy behavioral state, to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply. 1. Swaddle or tightly bundle the baby. 2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby

2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby 1. Babies who are in the drowsy behavioral state and who are tightly swaddled often fall asleep rather than become aroused. 2. The smell and/or the taste of the milk often will arouse a drowsy baby. 3. Drowsy babies will open their eyes when placed in the en face position and are interacted with. 4. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby. 5. Performing manipulations like diapering or playing pat-a-cake often will arouse a drowsy baby.

A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope in order to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

2. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope). 1. Heat loss resulting from evaporation occurs when the baby is wet and exposed to the air. 3. Heat lost resulting from radiation occurs when the baby is exposed to cool objects that the baby is not in direct contact with. 4. Heat lost resulting from convection occurs when the baby is exposed to the movement of cooled air—for example, air conditioning currents.

A neonate has just been born with a meningomyelocele. Which of the following nursing diagnoses should the nurse identify as related to this medical diagnosis? 1. Deficient fluid volume. 2. High risk for infection. 3. Ineffective breathing pattern. 4. Imbalanced nutrition: less than body requirements.

2. High risk for infection.: If the fragile sac is injured, the baby is very high risk for infection. meningomyelocele, a form of spina bifida (occurs when the spine and spinal cord don't form properly), are at very high risk for infection in the central nervous system until the defect is corrected.

A client is 3-days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.

2. Hydralazine is an antihypertensive. The change in blood pressure indicates that the medication is effective.

A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

2. If a baby does not breathe, the remaining physiological transitions cannot successfully take place. oooof LOL

A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6ºF, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain.

2. Infection is the priority nursing diagnosis. A temperature of 104.6ºF, as well as the client's other signs/symptoms, should immediately suggest the presence of infection.

A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? 1. "Any powder made especially for babies should be fine." 2. "It is recommended that powder not be put on babies." 3. "There is no real difference except that many babies are allergic to cornstarch so it should not be used." 4. "As long as you only put it on the buttocks area, you can use any brand of baby powder that you like."

2. It is recommended that powders, even if advertised for the purpose, not be used on babies.

Which of the following actions would the NICU nurse expect to perform when caring for a neonate with esophageal atresia and tracheoesophageal fistula (TEF)? 1. Position the baby flat on the left side. 2. Maintain low nasogastric suction. 3. Give small frequent feedings. 4. Place on hypothermia blanket.

2. Low nasogastric suction is usually maintained to minimize the amount of the baby's oral secretions 1. Babies with tracheoesophageal fistula (TEF) usually have the heads of their cribs elevated. The babies may be placed on one of their sides but should not be laid flat. 3. Babies that are born with TEF are kept NPO (nothing by mouth). 4. There is no reason to place a TEF baby on a hypothermia blanket.

The third stage of labor has just ended for a client who has decided to bottlefeed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

2. Prolactin will elevate sharply in the client's bloodstream. 1. Estrogen drops precipitously after the placenta is delivered. 3. Human placental lactogen drops precipitously after the placenta is delivered. 4. Human chorionic gonadotropin is produced by the fertilized ovum.

An 18-hour-old baby is placed under the bili-lights with an elevated bilirubin level. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy after all feedings. 2. Rotate the baby from side to back to side to front every two hours. 3. Tightly swaddle in baby blankets to maintain normal temperature. 4. Administer intravenous fluids via pump per doctor orders.

2. Rotating the baby's position maximizes the therapeutic response because the more skin surface that is exposed to the light source, the better the results. 1. The neonate needs nourishment with formula and/or breast milk. 3. The skin surface must be exposed to the light source so swaddling is contraindicated. 4. Intravenous fluids would be administered only under extreme circumstances.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2. She feeds her baby every 2 to 3 hours.

A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse expect the neonatalogist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds.

2. Since peak bilirubin levels are seen between days 3 and 5, and since the level is well within normal range, the nurse should expect that the baby will be discharged home with parents.

A 1000-gram neonate is being admitted to the neonatal intensive care unit. The surfactant Survanta (beractant) has just been prescribed to prevent respiratory distress syndrome. Which of the following actions should the nurse take while administering this medication? 1. Flush the intravenous line with normal saline solution. 2. Assist the neonatalogist during the intubation procedure. 3. Inject the medication deep into the vastus lateralis muscle. 4. Administer the reconstituted liquid via an oral syringe.

2. Surfactant is administered intratracheally. The baby must first be intubated. The nurse would assist the doctor with the procedure.

A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following laboratory values indicates that the medication is effective? 1. PT (prothrombin time): 12 sec (normal is 10-13 seconds). 2. INR (international normalized ratio): 2.5 (normal is 1.0-1.4). 3. Hematocrit 55%. 4. Hemoglobin 10 g/dL.

2. The INR should be between 2 and 3. Coumadin interferes with the clotting of blood. The PT and/or INR will be monitored to determine whether or not the medication is effective. If the PT is more than 2 times normal or the INR is over 3, the client is at high risk for hemorrhage.

A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

2. The action is appropriate. The woman should breastfeed frequently. If the mother were to wean abruptly, milk stasis would occur, the bacteria would proliferate, and a breast abscess is likely to develop. The mother should feed her baby frequently, use warm soaks to promote milk flow, and notify her obstetrician.

At 1 minute of life a baby, who appears preterm, has exhibited no effort to breathe even after being stimulated. Which of the following actions should the nurse perform first? 1. Perform a gestational age assessment. 2. Inflate the lungs with positive pressure. 3. Provide external chest compressions. 4. Palpate the base of the umbilical cord.

2. The baby's airway should be established by inflating the lungs with an ambu bag. Airway breathing circulation 1. The gestational age assessment should be performed only after resuscitation efforts have been performed. 3. Chest compressions are begun after an airway is established and the heart rate has been assessed. 4. Heart rate assessment should be performed after an airway has been established.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lbs 2 oz, 21 inches long, TPR: 96.6ºF, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following actions should the nurse perform first? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2. The glucose level should be assessed to determine whether or not this baby is hypoglycemic. 1. This baby is hypothermic, but the best intervention would be to place the baby under a warmer rather than to swaddle the baby. Plus, the baby's glucose levels must be assessed in order to determine whether or not this baby is hypoglycemic. The glucose can be evaluated while the baby is under the warmer. 3. A feeding will elevate the glucose level if it is below normal. The nurse does need to assess the level, however, in order to make a clear determination of the problem. 4. The administration of the neonatal medicines is not a priority at this time.

A client is seeking preconception counseling. She has type 1 diabetes mellitus and is found to have an elevated glycosylated hemoglobin (HgbA1c) level. Before actively trying to become pregnant, she is strongly encouraged to stabilize her blood glucose to reduce the possibility of her baby developing which of the following? 1. Port wine stain. 2. Cardiac defect. 3. Hip dysplasia. 4. Intussusception.

2. The incidence of cardiac defects and neural tube defects is high in infants born to diabetic mothers. ____________________________________ 4. Intussusception is an invagination of the small intestine. It is unrelated to a maternal diagnosis of diabetes

A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

2. The nurse is being a patient advocate since the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medications be used during all circumcision procedures. 1. Circumcision is a surgical procedure that requires a sterile field and sterile technique. The nurse is performing safe practice in this situation. 3. If a baby feeds immediately before the circumcision, he may aspirate his feeds. This is safe practice. 4. To make sure the baby is not hemorrhaging at the incision site is also an example of safe nursing practice.

The nurse administers Lanoxin (digoxin) to a baby in the NICU that has a cardiac defect. The baby vomits shortly after receiving the medication. Which of the following actions should the nurse perform next? 1. Give a repeat dose. 2. Notify the physician. 3. Assess the apical and brachial pulses concurrently. 4. Check the vomitus for streaks of blood.

2. The nurse should notify the physician that the baby has vomited the digoxin. 1. The dose should not be readministered until it has been determined that the child's digoxin levels are within normal limits. 3. This action is not needed. The apical pulse will have been assessed prior to the initial administration of the medication and assessing the two pulses together will provide no further information. 4. It is unlikely that the vomitus will be streaked with blood.

A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

2. The nurse would expect the client to complain of a severe postural headache. Only spinal clients, most notably those who elevate soon after surgery, are at high risk for postural headaches.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit 39%. 2. White blood cell count 16,000 cells/mm3. 3. Red blood cell count 5 million cells/mm3. 4. Hemoglobin 15 grams/dL.

2. The nurse would expect to see an elevated white cell count. 1. The hematocrit is often low in postpartum clients. 3. The red cell count is often low in postpartum clients. 4. The hemoglobin is often low in postpartum clients

Monochorionic twins, whose gestation was complicated by twin-to-twin transfusion, are admitted to the neonatal intensive care unit. Which of the following characteristic findings would the nurse expect to see? 1. Recipient twin has petechial rash. 2. Recipient twin is 20% larger than the donor twin. 3. Donor twin has 30% higher hematocrit than recipient twin. 4. Donor twin is ruddy and plethoric.

2. The recipient is likely to be at least 20% larger than the donor twin. 1. The recipient twin's appearance is not characterized by the development of a rash. 3. The recipient, rather than the donor, will have an elevated hematocrit. 4. The recipient, rather than the donor, will be ruddy and plethoric.

A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the affect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

2. The therapeutic effect of selective serotonin receptor inhibitors (SSRIs) like Zoloft is delayed about 1 to 2 weeks from the time the medication is initiated.

The parents and their full-term, breastfed neonate were discharged from the hospital. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? 1. The parents weigh their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician.

4. The baby should be seen by the pediatrician.

For which of the following reasons would a nurse in the well baby nursery report to the neonatalogist that a newborn appears to be preterm? 1. Baby has a square window angle of 90º. 2. Baby has leathery and cracked skin. 3. Baby has popliteal angle of 90º. 4. Baby has pronounced plantar creases.

1. A baby whose square window sign is 90˚ is preterm. 2. A baby whose skin is cracked and leathery is exhibiting a sign of postmaturity. 3. A baby whose popliteal angle is 90˚ is full term. 4. A baby whose plantar creases are pronounced is full term.

A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? 1. "The baby received passive immunity through the placenta, plus the breast milk will also be protective." 2. "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." 3. "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." 4. "Because chickenpox is a spirochetal illness, both the child and baby should receive the appropriate medications."

1. "The baby received passive immunity through the placenta, plus the breast milk will also be protective."

A nurse working with a 24-hour-old neonate in the well baby nursery has made the following nursing diagnosis: Risk for altered growth. Which of the following assessments would warrant this diagnosis? 1. The baby has lost 8% of weight since birth. 2. The baby has not urinated since birth. 3. The baby weighed 3000 grams at birth. 4. The baby exhibited signs of torticollis.

1. A baby who has lost 8% of his or her weight after only 24 hours of life is very high risk for altered growth. (The normal weight loss for newborn babies is between 5% and 10%. An 8% loss during the first 24 hours, therefore, places this baby at high risk for altered growth) 2. Although a problem, the fact that the baby has yet to urinate does not indicate a risk for altered growth. 3. The average weight of a full-term neonate is between 2500 and 4000 grams. A baby weighing 3000 grams, therefore, is well within norms. 4. Torticollis is a birth injury characterized by an abnormal positioning of the head. The head is deviated to one side.

On admission to the nursery, a baby's head and chest circumferences are 39 cm and 32 cm, respectively. Which of the following actions should the nurse take next? 1. Assess the anterior fontanel. 2. Measure the abdominal girth. 3. Check the apical pulse rate. 4. Monitor the respiratory effort.

1. Because the head circumference is significantly larger than the chest circumference, the nurse should assess for another sign of hydrocephalus. A markedly enlarged or bulging fontanel is one of those signs. 2. Abdominal girth does not change when a child has hydrocephalus. 3. Hydrocephalus is not a cardiovascular problem. 4. Hydrocephalus is not a respiratory problem.

The nurse suspects that a newborn in the nursery has a clubbed right foot because the foot is plantar flexed and because the nurse also notices which of the following? 1. Inability to move the foot into proper alignment. 2. Notes positive Ortolani sign on the right. 3. Notes shortened right metatarsal arch. 4. Elicits positive Babinski reflex on the right.

1. During the neonatal physical assessment, the nurse is unable to move a club foot into proper alignment.

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. 1. Hyperphagia. 2. Lethargy. 3. Prolonged periods of sleep. 4. Hyporeflexia. 5. Persistent shrill cry.

1. Hyperphagia. 5. Persistent shrill cry. 1. Babies with signs of neonatal abstinence syndrome repeatedly exhibit signs of hunger. 2. Babies with neonatal abstinence syndrome are hyperactive, not lethargic 3. Babies with neonatal abstinence syndrome often exhibit sleep disturbances rather than prolonged periods of sleep. 4. Babies with signs of neonatal abstinence syndrome are hyperreflexic, not hyporeflexic. 5. Babies with signs of neonatal abstinence syndrome often have a shrill cry that may continue for prolonged periods.

Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink iced tea with lemon or lime.

1. Lie prone with a small pillow cushioning her abdomen.

A neonate is being given intravenous fluids through the dorsal vein of the wrist. Which of the following actions by the nurse is essential? 1. Tape the arm to an arm board. 2. Change the tubing every 24 hours. 3. Monitor the site every 5 minutes. 4. Infuse the fluid intermittently.

1. Neonates are incapable of controlling their movements. In order to maintain a safe IV site, it is essential to tape the baby's arm to an arm board.

A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following PRN medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

1. Reglan is an antiemetic. It is the drug of choice for a client who is vomiting after surgery. 2. Demerol is a narcotic analgesic. It is not the appropriate medication for this client. 3. Seconal is a sedative. It is not the appropriate medication for this client. 4. Benadryl is an antihistamine. It is not the appropriate medication for this client.

Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hematocrit 24%. 2. Leukocyte count 45,000 cells/mm3. 3. Sodium 125 mEq/L. 4. Potassium 5.5 mEq/L.

1. The baby with erythroblastosis fetalis would exhibit signs of severe anemia, which a hematocrit of 24% reflects

The nurse in the obstetric clinic received a telephone call from a bottlefeeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.

1. The client should apply ice packs to her axillae and breasts. 2. Engorgement will not be relieved by applying lanolin to the breasts. And the act of applying the lanolin may actually stimulate milk production. 3. If the woman expresses milk from her breasts, she will stimulate the breasts to produce more milk. 4. The Food and Drug Administration (FDA) recommends that milk suppressants not be administered because of the serious side effects of the medications

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

1. The client with postpartum psychosis will experience hallucinations. (experience hallucinations, usually auditory, including voices that may tell them to kill their babies.) 2. Clients with diabetes mellitus, not postpartum psychosis, are polyphagic. 3. Clients with bulimia induce vomiting. 4. Clients with postpartum blues and/or postpartum depression are weepy and sad.

The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching? 1. Always wipe the perineum from front to back. 2. Remove any vernix caseosa from the labial folds. 3. Put powder on the buttocks every time the baby stools. 4. Weigh every diaper in order to assess for hydration.

1. The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection.

A client has been transferred to the post-anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit

The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

1. When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficient milk may be produced.

Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing.

2, 3, 4, and 5 are correct. 1. Abductors usually plan their strategies carefully before taking the baby. 2. A common diversion is pulling the fire alarm to distract the staff. 3. Those who are inquisitive about where babies are at different times of the day may be planning an abduction. 4. Rooms near stairwells provide the abductor with a quick and easy get-away. 5. The abductor is able to hide a baby in oversized clothing or in large bags.

A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives."

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles could the nurse safely choose for the injection? 1. 5⁄8 inch, 18 gauge. 2. 5⁄8 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

2. A 5⁄8-inch, 25-gauge needle is an appropriate needle for a neonatal IM injection.

A baby is suspected of having esophageal atresia. The nurse would expect to see which of the following signs/symptoms? 1. Frequent vomiting. 2. Excessive mucus. 3. Ruddy complexion. 4. Abdominal distention.

2. Babies with esophageal atresia would be expected to expel large amounts of mucus from the mouth. 1. Vomiting is literally impossible. 3. A ruddy complexion is related to polycythemia, not esophageal atresia. 4. Abdominal distension is not related to esophageal atresia

Four babies in the well baby nursery were born with congenital defects. Which of the babies' complications developed as a result of the delivery method? 1. Club foot. 2. Brachial palsy. 3. Gastroschisis. 4. Hydrocele.

2. Brachial palsy can result from either a traumatic vertex or breech delivery.

A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible.

2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. The nurse should treat this baby with care and concern. Even though the baby has died he is still a valued child to the parents. The parents should be asked whether they would like to see or hold their baby.

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. 1. The uterus is contracted. Massaging the uterus will not remedy the problem of heavy lochial flow. 3. An oxytocic promotes contraction of the uterine muscle. The muscle is already contracted. 4. The uterus is at the umbilicus. It is unlikely that it is displaced from a full bladder

A nurse is assisting a mother to feed a baby born with cleft lip and palate. Which of the following should the nurse teach the mother? 1. The baby is likely to cry from pain during the feeding. 2. The baby is likely to expel milk through the nose. 3. The baby will feed more quickly than other babies. 4. The baby will need milk with added calories.

2. It is likely that milk will be expelled from the baby's nose during feedings. 1. It is not painful for a cleft lip and palate baby to feed. 3. Babies with clefts often take much longer to feed than do other babies. 4. Babies with clefts usually consume the same milk, either breast milk or formula, that other babies consume.

A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

2. Protamine is the antidote for heparin overdose. On the other hand, the antidote for Coumadin, another medication often administered to clients with DVT, is vitamin K.

A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? 1. Cover the wound with sterile wet dressings. 2. Notify the surgeon. 3. Elevate the head of the client's bed slightly. 4. Flex the client's knees.

2. The highest priority action is to notify the surgeon. ________________________________ 1. After the surgeon is notified, the nurse should stay with the patient while another staff member gathers supplies, including a suture removal kit and personal protective equipment as well as sterile saline solution and a large syringe.

A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus.

A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are +4. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

2. The nurse should notify the physician of the signs of preeclampsia.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2. The nurse stabilizes the base of the uterus with his or her dependent hand.

During a postpartum assessment, the nurse performs a Homan's sign. Which of the following actions does the nurse perform? 1. Taps the patellae with a reflex hammer. 2. Dorsiflexes the feet. 3. Palpates the calves and ankles. 4. Monitors the color of the extremities.

2. The nurse would dorsiflex the feet when performing Homan's sign After dorsiflexing a foot, the nurse would ask the client whether or not she felt pain in the calf of her leg.

A client, G1P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad

2. This action is the first that the nurse should take. all other actions necessary but not first action

The nurse informs a postpartum woman that ibuprofen (Advil) is especially effective for afterbirth pains. What is the scientific rationale for this? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen is administered in high doses.

2. This statement is correct. Ibuprofen has an antiprostaglandin effect.

A baby in the newborn nursery was born to a mother with spontaneous rupture of membranes for 14 hours. The woman has Candida vaginitis. For which of the following should the baby be assessed? 1. Papular facial rash. 2. Thrush. 3. Fungal conjunctivitis. 4. Dehydration

2. Thrush is commonly seen in babies whose mothers have Candida vaginitis.

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4660 grams. 3. Baby with temperature 97.8ºF, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2. the baby's weight—4660 grams—is well above the average of 2500 to 4000 grams. Babies who are large-for-gestational age are at high risk for hypoglycemia. 1. Respiratory rate between 30 and 60 and oxygen saturation above 95% are normal findings. 3. Temperature 97.7º to 99ºF and length 18 to 22 inches are normal findings. 4. Blood glucose 40 to 60 mg/dL and heart rate 120 to 160 bpm are normal findings.

The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range of motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

3. Active range of motion exercises will help to prevent thrombus formation in C/section patients.

A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies can taste only salty and sour substances at birth." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age."

3. Babies' sense of touch is considered to be the most well-developed sense. 1. All of the babies' senses are well developed at birth. 2. Babies respond to all forms of taste. They prefer sweet things. 4. Babies see quite well at 8 to 12 inches. They prefer to look at the human face

The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells—12,500 cells/mm3. 2. Red blood cells—4,500,000 cells/mm3. 3. Hematocrit—26%. 4. Hemoglobin—11 g/dL

3. Hematocrit—26%. hemo 15% hema 35%

The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? 1. Clean the eyes from outer canthus to inner canthus. 2. Cleanse the ear canals with a cotton swab. 3. Assemble all supplies before beginning the bath. 4. Check the temperature of the bath water with fingertips.

3. If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet.

The day after delivery a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3. Inform the client that polyuria is normal.

A woman, who wishes to breastfeed, advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate? 1. Advise the woman that unfortunately she will be unable to breastfeed. 2. Examine the woman's breasts to see where the incision was placed. 3. Monitor the baby's daily weights for excessive weight loss. 4. Inform the woman that reduction surgery rarely affects milk transfer.

3. Monitor the baby's daily weights for excessive weight loss During breast reduction surgery, fat tissue is removed from the breast. Because the breast is much smaller, the nipple must be moved to a new location. During these procedures, the client's mammary ducts may be ligated. If the ducts are severed, the woman will not be able to transfer the milk produced in her glandular tissue to the baby

A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9ºF. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.

3. Preterm babies are born with an insufficient supply of brown adipose tissue that is needed for thermogenesis, or heat generation. 1. The normal temperature of a premature baby is the same as a full-term baby. 2. Axillary temperatures, when performed correctly, provide accurate information. 4. There is nothing in the question that would explain conduction heat loss.

A child has been diagnosed with a small ventricular septal defect (VSD). Which of the following symptoms would the nurse expect to see? 1. Cyanosis and clubbing of the fingers. 2. Respiratory distress and extreme fatigue. 3. Systolic murmur with no other obvious symptoms. 4. Feeding difficulties with marked polycythemia.

3. Systolic murmur with no other obvious symptoms.

A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place child in isolette. 2. Administer oxygen. 3. Swaddle baby in blanket. 4. Apply pulse oximeter.

3. The baby's extremities are cyanotic as a result of the baby's immature circulatory system. Swaddling helps to warm the baby's hands and feet.

A baby is born to a mother who was diagnosed with oligohydramnios during her pregnancy. The nurse notifies the neonatalogist to order tests to assess the functioning of which of the following systems? 1. Gastrointestinal. 2. Hepatic. 3. Endocrine. 4. Renal.

4 Real: Some defects of the renal system can lead to oligohydramnios. most of the amniotic fluid produced during a pregnancy is produced by the fetal kidneys and is fetal urine. If there is a defect in the renal system, there may be a resulting decrease in the amount of fetal urine produced. Oligohydramnios would then result.

The nurse must perform nasopharyngeal suctioning of a newborn with profuse secretions. Place the following nursing actions for nasopharyngeal suctioning in chronological order. 1. Slowly rotate and remove the suction catheter. 2. Place thumb over the suction control on the catheter. 3. Assess type and amount of secretions. 4. Insert free end of the tubing through the nose.

4, 2, 1, and 3 is the correct order. 1. Rotation and removal of the suction catheter should be done after the tubing has been inserted through the nose and a thumb placed over the suction control on the catheter. 2. The nurse should place a thumb over the suction control on the catheter after inserting the free end of the tubing through the nose—and before the other two steps are taken. 3. Assessing the type and amount of secretions in the last step in the process. 4. Inserting the free end of the tubing through the nose is the first step in nasopharyngeal suctioning process.

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every 1⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

4. "The physician should see you. Please come in whenever you are ready." A heavy discharge is described as a discharge that saturates a pad in 1 hour or less. Since this client's lochia has already changed to alba (whitish), it is especially concerning that she is now experiencing a heavy lochia rubra (reddish) flow

The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounce yogurt mixed with 1 medium banana. 3. 12 ounce strawberry milk shake. 4. 1 1⁄2 cup raw broccoli.

4. 11⁄2 cup raw broccoli.

The nurse caring for a neonate with congestive heart failure identifies which of the following nursing diagnoses as highest priority? 1. Fatigue. 2. Activity intolerance. 3. Sleep pattern disturbance. 4. Altered tissue perfusion.

4. Altered tissue perfusion.

A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks

4. Vitamin K is needed for adequate blood clotting.

Using the Neonatal Infant Pain Scale (NIPs), a nurse is assessing the pain response of a newborn who has just had a circumcision. A change in which of the following signs/symptoms is the nurse evaluating? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

4. Facial expression is one variable that is evaluated as part of the NIPS scale. 5. Breathing pattern is one variable that is evaluated as part of the NIPS scale. 1. Although assessed in other pain scales, the heart rate is not part of the NIPS scale. 2. Blood pressure is not assessed in any infant pain scale. 3. Temperature is not assessed in any infant pain scale.

A newborn admitted to the nursery has a positive direct Coombs' test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice

4. When the neonatal bloodstream contains antibodies, hemolysis of the red blood cells occurs and jaundice develops

A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

1. Babies with short frenulums—tonguetied babies—are unable to extend their tongues enough to achieve a sufficient grasp. Painful and damaged nipples often result.

A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

1. Both the upper and lower lips should be flanged. 2. Breastfed babies usually feed every 2 to 3 hours. 3. A 12% weight loss is significant in any neonate whether breastfeeding or bottlefeeding. 4. When the tongue stays behind the gum line the baby is unable to strip the breast of milk.

The nurse has provided teaching to a post-op cesarean client who is being discharged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman does not worry when her urine turns orange.

1. Colace capsules should not be crushed, broken, or chewed.

A newborn in the NICU has just had a ventriculoperitoneal shunt inserted. Which of the following signs indicates that the shunt is functioning properly? 1. Decrease of the baby's head circumference. 2. Absence of cardiac arrhythmias. 3. Rise of the baby's blood pressure. 4. Appearance of setting sun sign.

1. Decrease of the baby's head circumference. Ventriculoperitoneal (VP) shunts are inserted for the treatment of hydrocephalus. A positive finding, therefore, would be decreasing head circumferences.

The nurse is initiating discharge teaching with a couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. on admission to the labor room. 2. in the client room after the delivery. 3. when the client put the baby to the breast for the first time. 4. the day before the client and baby are to leave the hospital.

1. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room.

Which of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The client will not develop postpartum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high fiber foods.

1. Early ambulation does help to prevent thrombophlebitis.

Four babies are in the newborn nursery. The nurse pages the neonatalogist to see the baby who exhibits which of the following? 1. Intracostal retractions. 2. Erythema toxicum. 3. Pseudostrabismus. 4. Vernix caseosa.

1. Intracostal retractions are symptomatic of respiratory distress syndrome. 2. Erythema toxicum is the normal newborn rash. 3. Pseudostrabismus is a normal newborn finding. 4. Vernix caseosa is the cheesy material that covers many babies at birth.

A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? 1. Put the car seat facing forward only after the baby reaches twenty pounds. 2. The baby's car seat should be placed facing the rear in the front seat of the car. 3. A fist should fit between the straps of the seat and the baby's body. 4. Seat belt adjusters should always be used to support infant car seats.

1. It is unsafe for infants to be facing forward until they have reached 20 pounds, even if they are over 1 year of age.

A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

1. Palpate the breasts. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks and torso. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 4. Sharply demarcated dark red area on the face. 5. Deep hair-covered dimple at the base of the spine.

1. Purple-colored patches on the buttocks and torso. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 1. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 2. The whitish discharge is called witch's milk and is excreted as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 4. The demarcated area is a port wine stain, or capillary angioma. It is a permanent birthmark. 5. The dimple may be a pilonidal cyst or a small defect into the spinal cord (spina bifida). An ultrasound should be done to determine whether or not a pathological condition is present.

Which of the following full-term babies requires immediate intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of 52.

1. Seesaw breathing is an indication of respiratory distress. 2. This is the normal breathing pattern of a neonate. 3. When babies breathe, their abdomens and thoraces rise and fall in synchrony. 4. The normal respiratory rate is 30 to 60 bpm.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

1. The appropriate action is to provide the client with warm blankets. 2. Postpartum shaking is very common. It is unnecessary to place the client in the Trendelenburg position. 3. Postpartum shaking is very common. It is unnecessary to notify the client's health care provider. 4. Postpartum shaking is very common. It is unnecessary to increase the client's intravenous fluid rate.

Four 38-week-gestation gravidas have just delivered. Which of the babies should be monitored closely by the nurse for respiratory distress? 1. The baby whose mother has diabetes mellitus. 2. The baby whose mother has lung cancer. 3. The baby whose mother has hypothyroidism. 4. The baby whose mother has asthma.

1. The lung maturation of infants of diabetic mothers is often delayed. These babies must be monitored at birth for respiratory distress. 2. A maternal diagnosis of lung cancer will not affect her neonate's pulmonary function. 3. A maternal diagnosis of hypothyroidism does not put the baby at high risk for respiratory distress. 4. A maternal diagnosis of asthma does not put the baby at high risk for respiratory distress.

The obstetrician has ordered that a post-op cesarean section client's patient controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet.

1. This answer is correct. Because the medication in a PCA pump is controlled by law, the medication must be wasted in the presence of another nurse. _________________________________________ 2. This answer is inappropriate. A pain level of 0 is unrealistic after abdominal surgery. The nurse, however, should request that the doctor order one of the many oral analgesics

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottlefeed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding.

1. This answer is correct. She should gently massage the area toward the nipple. A client who palpates a tender, hard nodule in her lactating breast is experiencing milk stasis. The stasis may be related to a blocked milk duct. 2. The woman should apply warm soaks, not ice. 3. The woman should be advised to feed her baby frequently at the breast. She should not be advised to bottlefeed. 4. The woman should apply lanolin (Lansinoh) to sore or cracked nipples, not for a problem of tender hard nodules.

A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum check-up. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period.

1. This response is correct. The couple is encouraged to wait until after involution is complete. 2. Although some clients do begin having intercourse once the episiotomy is healed and lochia stops, it is recommended that clients wait the full 6 weeks. 3. The couple is encouraged to wait until after involution is complete. 4. The couple is encouraged to wait until after involution is complete.

A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the immediate postpartum period.

1. This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant. 2. This statement is incorrect. The immune systems of women during their pregnancies and immediately postpartum are slightly depressed. 3. This statement is incorrect. The baby will be susceptible to rubella whether or not the woman receives the vaccine.

A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. The mother must wear a surgical mask when she cares for the baby. 4. Passive antibodies transported across the placenta will protect the baby.

1. This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection.

A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula

1. Tightly swaddling drug-addicted babies often helps to control the hyperreflexia that they may exhibit. 2. Placing hyperactive babies on their abdomens can result in skin abrasions on the face and knees from rubbing against the linens. 3. Drug-exposed babies should be placed in a low-stimulation environment. 4. The babies should be given small frequent feedings either of formula or of breast milk.

The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be taught that toned pubococcygeal muscles decrease blood loss.

2. She should practice by stopping the urine flow

A 30-week-gestation neonate, 2 hours old, has received Survanta (beractant). Which of the following would indicate a positive response to the medication? 1. Axillary temperature 98.0ºF. 2. Oxygen saturation 96%. 3. Apical heart rate 154 bpm. 4. Serum potassium 4.0 mEq/L.

2. A normal oxygen saturation level would be considered a positive result of the medication.

The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Get the woman an order for a topical anesthetic

2. A small amount of lanolin should be applied to the nipple after each feeding. 1. The woman should not wash with soap. Soaps destroy the natural lanolins produced by the body. 3. The baby will not become sick from the blood. The woman should be warned that he may spit up digested and/or undigested blood after the feeding, however. 4. Topical anesthetics are not used on the breasts. The woman could receive an oral analgesic, however

The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is high risk for infection and must be protected.

2. Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B. If the woman is infected with those viruses, the amniotic fluid will be infectious. 1. Meconium is a sterile stool. Plus the newborn will not produce gastrointestinal bacteria until a few days after delivery. 3. Fetal urine is not highly alkaline. 4. Although babies are at high risk for infection, there is no need for nurses to wear gloves routinely when caring for the babies. Immediately after delivery the nurse is protecting himself or herself from the baby, not the other way around.

A breastfeeding client, G10P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2. An assessment of the woman's fundus is the most important assessment to perform on this client. 1. An assessment of the woman's pulse rate is important, but it is not the most important assessment. 3. An assessment of the woman's bladder is important, but it is not the most important assessment. 4. An assessment of the woman's breasts is important, but is not the most important assessment

A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would the nurse expect to see? 1. Ruddy complexion. 2. Anasarca. 3. Alopecia. 4. Erythema toxicum

2. Babies born with erythroblastosis fetalis often are in severe congestive heart failure and, therefore, exhibit anasarca.

A nurse in the newborn nursery suspects that a new admission, 42 weeks' gestation, was exposed to meconium in utero. What would lead the nurse to suspect this? 1. The baby is bradycardic. 2. The baby's umbilical cord is green. 3. The baby's anterior fontanel is sunken. 4. The baby is desquamating.

2. Because meconium is a dark green color, when it is expelled in utero, the baby can be stained green. 1. Bradycardia is a sign of neonatal distress but it is not related to meconium exposure. 3. A sunken fontanel is an indication of dehydration, not of meconium exposure. 4. A baby's skin often desquamates when he or she is postterm. Although meconium may be expelled by a post-term baby, desquamation is not related to the meconium.

A newborn nursery nurse notes that a baby's body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2. Bilirubin is excreted through the bowel. The more the baby consumes, the more stools, and therefore the more bilirubin the baby will expel.

A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding? 1. Have the woman wean the baby to formula. 2. Have the baby stay in the hospital room with the mother. 3. Have the woman pump and dump her milk for two weeks. 4. Have the baby bottlefed milk that the mother has stored.

2. Optimally, the baby should stay in the hospital room with the mother

A baby born addicted to cocaine is being given paregoric. The nurse knows that which of the following is a rationale for its use? 1. Paregoric is nonaddictive. 2. Paregoric corrects diarrhea. 3. Paregoric is nonsedating. 4. Paregoric suppresses the cough reflex.

2. Paregoric does help to control the diarrhea seen in drug-addicted neonates. 1. Paregoric contains morphine. It is addictive. 3. Paregoric does cause drowsiness. 4. Sneezing is a symptom seen in drugaddicted neonates, not coughing.

A baby is born with caudal agenesis. Which of the following maternal complications is associated with this defect? 1. Poorly controlled myasthenia gravis. 2. Poorly controlled diabetes mellitus. 3. Poorly controlled splenic syndrome. 4. Poorly controlled hypothyroidism.

2. Poorly controlled maternal diabetes mellitus is one of the most important predisposing factors for caudal agenesis in the fetus. Caudal regression syndrome, or sacral agenesis (or hypoplasia of the sacrum), is a congenital disorder in which there is abnormal fetal development of the lower spine

A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation.

2. Putting direct pressure on the site is the best way to stop the bleeding. __________________ 4. Only after performing first aid should the nurse assess the vital signs.

In the delivery room, which of the following infant care interventions must a nurse perform when a neonate with a meningomyelocele is born? 1. Perform nasogastric suctioning. 2. Place baby in the prone position. 3. Administer oxygen via face mask. 4. Swaddle the baby in warm blankets.

2. The baby should be lain prone to prevent injury to the sac - born with an opening at the base of the spine through which a sac protrudes

A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatalogist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the neonatal eye prophylaxis.

2. The neonatalogist must be called to the delivery room so that he or she arrives before the baby is delivered. 1. The warmer must be preheated, but that is not the priority at this time. 3. The woman did receive a narcotic analgesic 4 hours ago. Although Narcan may be needed, she has likely metabolized most of the medication by this time. The medication is not a priority at this time. 4. The eye prophylaxis can wait until this baby is at least 1 hour old. It is not a priority at this time.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

2. The nurse would expect that the client would have lochia alba. 1. Diaphoresis has usually subsided by this time. 3. The nurse would not expect the client's nipples to be cracked. 4. The nurse would not expect the client to be hypertensive.

A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104. 2. Urinary output 240 cc/12 hr. 3. Blood pressure 160/120. 4. Temperature 100ºF.

2. The urinary output is the likely cause of the client's changes The hourly output for this client is 20 cc/hr. This is well below the minimum urinary output of 30 cc/hr. Since the medication is excreted via the kidneys, when a client's output is low, the concentration of the medication can increase to toxic levels in the bloodstream. This client is exhibiting signs of magnesium toxicity.

A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents.

2. This action is appropriate. The nurse is acknowledging that every member of the family is grieving the loss. 1. This father is grieving. His anger is appropriate at this time. 3. Five-year-old children do not understand death. They do respond to their parents' unusual behaviors. 4. Even though it is very difficult for the parents to deal with their own grief while caring for their daughter, the young girl may feel abandoned if sent unexpectedly to her grandparents.

A Roman Catholic couple has just delivered a baby with an Apgar of 1 at 1 minute, 2 at 5 minutes, and 2 at 10 minutes. Which of the following interventions is appropriate at this time? 1. Advise the parents that they should pray very hard so that everything turns out well. 2. Ask the parents whether they would like the nurse to baptize the baby. 3. Leave the parents alone to work through their thoughts and feelings. 4. Inform the parents that a priest will listen to their confessions whenever they are ready.

2. This baby's Apgar is very low. There is a chance that the baby will not survive. It is appropriate to ask the parents, since they are known to be Roman Catholic, if they would like their baby baptized 1. It is inappropriate to imply that, if a couple were to pray, that their sick child will be "all right." The baby may be seriously ill and even may die. 3. Although it is often easier for the nurse to leave parents alone whose babies are doing poorly, it is rarely therapeutic. 4. It is inappropriate to assume that the parents wish to give confession, although it may be appropriate to offer to have the priest visit them.

A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.

2. This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2. This information is correct. The blues usually resolve within 2 weeks of delivery. ___________________________ 3. Medications are usually not administered to relieve postpartum blues. Medications can be prescribed for clients who experience postpartum depression or postpartum psychosis.

The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steristrips to the incision line. 4. Palpate the incision for weaknesses.

2. This is appropriate. The nurse should assess for all signs on the REEDA scale.

A client who delivered a 3900-gram baby vaginally over a right lateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2. This is the best response. A right lateral episiotomy runs perpendicular to the perineum.

A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

2. This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit ABCs—airway, breathing, circulation

A breastfeeding woman, 1 1⁄2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2. This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex.

A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

2. This response gives the mother a brief scientific rationale for the medication administration.

The nurse takes a primipara her newborn for a feeding. The client holds the baby en face, strokes his cheek, and states that this is the first infant she has ever held. Which of the following nursing assessments is most appropriate? 1. Positive bonding and client needs little teaching. 2. Positive bonding but teaching related to infant care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.

2. This response is correct. The client is showing signs of positive bonding—en face positioning and stroking of the baby's cheeks—and is in need of information on child care

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.

2. This response is correct. The client is showing signs of positive bonding—en face positioning and stroking of the baby's cheeks—and is in need of information on child care. 1. Although the client is showing signs of positive bonding, she definitely needs a great deal of teaching. 3. This action is absolutely inappropriate at this time. There are no signs of poor bonding or of abuse. 4. There are no signs of poor bonding.

A post-cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

2. This statement is correct. One of the common side effects of narcotics is constipation. 1. The client's subjective pain level is 2/5. It is unlikely that she needs stronger medication. 3. This statement is incorrect. As long as the client feeds her baby frequently, the use of narcotics should not affect her milk production. 4. This statement is incorrect. This client's narcotic use is short term. Postoperative narcotic medications are considered safe for the breastfeeding baby. If the mother were a chronic narcotic user, the baby's response would be a concern.

A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? 1. "The baby does rarely open his mouth but you can see that he isn't in any distress." 2. "Babies usually breathe in and out through their noses so they can feed without choking." 3. "Everything about babies is small. It truly is amazing how everything works so well." 4. "You are right. I will report the baby's small nasal openings to the pediatrician right away."

2. This statement provides the mother with the knowledge that babies are obligate nose breathers in order to be able to suck, swallow, and breathe without choking.

The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby? 1. The baby will have a bath with soap every morning. 2. During a supervised play period, the baby will be placed on the tummy every day. 3. The baby will be given a pacifier after each feeding. 4. For the first month of life, the baby will sleep on its side in a crib next to the parents.

2. Tummy time, while awake and while supervised, helps to prevent plagiocephaly and to promote growth and development. 1. Babies do not need to have a full bath each day. Plus, daily soap baths can dry the newborn's skin. 3. Pacifiers have been recommended by the AAP for sleep, but there is no recommendation that babies be given a pacifier after every feeding. 4. It is strongly recommended that babies always be placed on their backs for sleep.

A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

2. When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages.

A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin

2. With lung oxygenation, the neonate no longer needs large numbers of red blood cells. As a result, excess red blood cells (RBCs) are destroyed. Jaundice often results on days 2 to 4. 1. This is a description of pathological jaundice resulting from maternal-fetal blood incompatibilities. 3. There is nothing in the scenario to suggest that this was a traumatic delivery. 4. There is nothing in the scenario to suggest that meconium excretion was delayed.

A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week check-up." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

3. "Daily exercise will help to prevent you from becoming diabetic in the future." Women who develop gestational diabetes are high risk for developing type 2 diabetes.

A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? 1. He holds the baby in the en face position. 2. He calls the baby by a full name rather than a nickname. 3. He tells the mother to pick up the crying baby. 4. He falls asleep in the chair with the baby on his chest.

3. A father who expects his partner to quiet a crying baby may not be accepting the parenting role. 4. Although this may not be the safest position for a baby to be sleeping, the father is showing a sign of positive bonding.

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hyperglycemia.

3. Babies who have lived in utero with an aging placenta usually are born with polycythemia. 1. The baby will likely be born with a normal platelet count. 2. The baby will likely be born with a normal white blood cell count. 4. Rather than hyperglycemia, babies who have lived in utero with an aging placenta usually are born with hypoglycemia.

A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h ! 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. Blood pressure.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Inform the neonate's pediatrician.

3. Diaphoresis is normal during the postpartum period. 1. It is unlikely that the woman is febrile. 2. The woman should maintain an adequate fluid intake. 4. There is no need to report the diaphoresis to the baby's pediatrician.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts.

3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. A hemoglobin of 7.2 g/dL, however, is well below the normal of 12 to 15 g/dL.

A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? 1. Notify the pediatrician immediately and report the finding. 2. Notify the social worker about the probable maternal abuse. 3. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear. 4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.

3. Subconjunctival hemorrhages are a normal finding and are not pathological. They will disappear over time. Explaining this to the mother is the appropriate action

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? 1. Xiphoid process. 2. Forehead. 3. Abdominal wall. 4. Great toe.

3. The abdominal wall is the appropriate placement for the skin thermal sensor.

The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

3. The drop in human placental lactogen (hPL) is related to the glucose level. The hormone hPL is an insulin antagonist. Once the placenta is birthed, however, the levels drop precipitously. As a result, it is not uncommon for the glucose levels of type 1 diabetics to be within normal limits for a day or so after delivery—as seen in this client

A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

3. The fundal response indicates that the medication was effective in contracting the uterus Methergine is an oxytocic agent. It is administered after delivery if the uterus is atonic or if the client is high risk for uterine atony

A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? 1. Cleanse it with hydrogen peroxide if it starts to smell. 2. Remove it with sterile tweezers at one week of age. 3. Call the doctor if greenish drainage appears. 4. Cover it with sterile dressings until it falls off.

3. The green drainage may be a sign of infection. The cord should become dried and shriveled.

A baby has been diagnosed with developmental dysplasia of the hip. Which of the following findings would the nurse expect to see? 1. Pronounced hip abduction. 2. Swelling at the site. 3. Asymmetrical leg folds. 4. Weak femoral pulses

3. The leg folds of the baby, both anteriorally and posteriorly, are frequently asymmetrical.

A client is 1-day post-cesarean delivery for eclampsia. The client is receiving 5% dextrose in 1⁄2 normal saline IV at 125 cc/hr and magnesium sulfate IV via infusion pump. Which of the following laboratory values should the nurse report to the surgeon? 1. Serum magnesium 7 mg/dL. 2. Serum sodium 136 mg/dL. 3. Serum potassium 3.0 mg/dL. 4. Serum calcium 9 mg/dL.

3. The serum potassium is below normal. The nurse should report the finding to the physician. 3.5-5.0 1. A magnesium level of 7 mg/dL is therapeutic. This is an expected level. 2. The serum sodium level is normal. 4. The serum calcium is normal.

A neonate, whose mother is HIV positive, is admitted to the NICU. A nursing diagnosis: Risk for infection related to perinatal exposure to HIV/AIDS is made. Which of the following interventions should the nurse make in relation to the diagnosis? 1. Monitor daily viral load laboratory reports. 2. Check the baby's viral antibody status. 3. Obtain an order for antiviral medication. 4. Place the baby on strict precautions.

3. The standard of care for neonates born to mothers with HIV/AIDS is to begin them on anti-AIDS medication in the nursery. The mother will be advised to continue to give the baby the medication after discharge. 1. The baby will have a positive antibody titer, as a result of passive immunity through the placenta, but there will be no evidence of active viral production that early in the newborn's life. 2. There is no need to assess the antibody titer. It will definitely be positive because the mother has HIV/AIDS. 4. There is no need to place the baby on strict precautions. The institution of standard precautions in the well-baby nursery is sufficient.

The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

3. The woman should turn, cough, and deep breathe every 2 hours.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? 1. The woman performs the procedure twice a day. 2. The woman sits in warm tap water for ten minutes. 3. The woman sprays her perineum from front to back. 4. The woman mixes tap water with hydrogen peroxide.

3. The woman sprays her perineum from front to back.

A client, G2P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

3. This action is very important. If the legs are removed from the stirrups one at a time, the woman is at high risk for back and abdominal injuries.

In which of the following situations would it be appropriate for the father to place the baby in the en face position? 1. The baby is asleep with little to no eye movement, regular breathing. 2. The baby is asleep with rapid eye movement, irregular breathing. 3. The baby is awake, looking intently at an object, irregular breathing. 4. The baby is awake, placing hands in the mouth, irregular breathing.

3. This baby is in the quiet alert behavioral state. Placing the baby en face will foster bonding between the father and baby

The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Ineffective lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

3. This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Posttrauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3. This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery.

The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

3. This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex.

The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy

3. This response is correct. The involution is normal and the lochia is rubra

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, I bet you have a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in for an assessment?"

3. This response is correct. The woman should be encouraged to use a lubricating jelly or oil.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line. 1. Episiotomy sutures are not removed. 2. Clients who have had episiotomies may or may not require pain medication. The medicine should be offered throughout the day since it is usually ordered prn. 4. It is not recommended to irrigate episiotomy incisions.

A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula.

3. Tickling the baby's lips with the nipple is the recommended method of encouraging a baby to open his or her mouth for feeding.

The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2ºF. 2. White blood cell count of 14,500 cells/mm3. 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

4. A malodorous lochial flow is a common sign of a puerperal infection. 1. Puerperal infection is defined as a temperature of 100.4˚F or higher after 24 hours' postpartum. 2. Although clients who develop endometritis will have significantly elevated white cell counts, a WBC count of 14,500 is normal for a postpartum client. 3. Clients who develop infections may perspire profusely. However, diaphoresis is normally seen in postpartum clients, and is not in itself indicative of postpartum infection.

A baby born by vacuum extraction has been admitted to the well baby nursery. The nurse should assess this baby for which of the following? 1. Pedal abrasions. 2. Hypobilirubinemia. 3. Hyperglycemia. 4. Cephalhematoma.

4. Babies born via vacuum are at high risk for cephalhematoma.

The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? 1. Molding of the baby's skull so that the baby could fit through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.

4. Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one sided or bilateral and the swellings do not cross suture lines.

The nurse observes a healthy woman of African descent expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

4. In Africa, breast milk is often expressed into babies' eyes to prevent neonatal eye infections. Asking the woman about other cultural traditions is appropriate.

A woman who has just delivered has decided to bottlefeed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle to keep the nipple filled with formula.

4. In order to minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is always filled with formula.

A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4. It is likely that this client is dehydrated. She should be advised to drink fluids 100.2 is not febrile

The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D.

4. Many babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn. For this reason, supplementation with vitamin D is recommended.

A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

4. This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of post surgical coughing 1. This response is accurate, but the nurse is exhibiting a lack of caring. 2. This response is inappropriate. Even if the lung fields are clear, the client should perform respiratory exercises. 3. This response is inappropriate. Simply breathing deeply may not be as effective as coughing.

A bottlefeeding woman, 1 1⁄2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

4. This response is appropriate. The client should be examined to assess her involution. 1. This response is not appropriate. This client is bleeding heavily and she is not breastfeeding. 2. It is unlikely that this client is menstruating since she is only 11 ⁄2 weeks postpartum. 3. This response is not appropriate. The client should not bleed heavily, especially so long after delivery.

A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpartum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."

4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to abdominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.