5 combine

Which substance, when abused during pregnancy, is the most significant cause of cognitive impairment and dysfunction in the infant? a. Alcohol b. Tobacco c. Marijuana d. Heroin

A. Alcohol Alcohol abuse during pregnancy is recognized as one of the leading causes of neurodevelopmental disorders in the United States. Alcohol is a teratogen; maternal ethanol abuse during gestation can lead to identifiable fetal alcohol spectrum disorders that include alcohol-related neurodevelopmental disorders. Cigarette smoking is linked to adverse pregnancy outcomes; the risk for placenta previa, placenta abruption, and premature rupture of membranes is twice that of nonsmokers. Marijuana is the most common illicit drug used by pregnant women. Marijuana crosses the placenta, and its use during pregnancy can result in shortened gestation and a higher incidence of IUGR.

A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana

A. Alcohol The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have a shrill cry and sleep-cycle disturbances and may exhibit with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy

A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the face and upper back. Which information regarding petechiae is most accurate and should be provided to the parents? a. Are benign if they disappear within 48 hours of birth b. Result from increased blood volume c. Should always be further investigated d. Usually occur with a forceps-assisted delivery

A. Are benign if they disappear within 48 hours of birth. Petechiae, or pinpoint hemorrhagic areas, acquired during childbirth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of childbirth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, alarming the family is not necessary. Petechiae usually occur with a breech presentation vaginal birth.

A number of common drugs of abuse may cross into the breast milk of a mother who is currently using these substances, which may result in behavioral effects in the newborn. Which substances are contraindicated if the mother elects to breastfeed her infant? (Select all that apply.) a. Cocaine b. Marijuana c. Nicotine d. Methadone e. Morphine

A. Cocaine B. Marijuana C. Nicotine The use of cocaine, marijuana, and nicotine are contraindicated during breastfeeding because of their reported effects on the infant. Morphine is a medication often used to treat neonatal abstinence syndrome. Maternal methadone maintenance is not a contraindication to breastfeeding

What is the most important nursing action in preventing neonatal infection? a. Good handwashing b. Isolation of infected infants c. Separate gown technique d. Standard Precautions

A. Good handwashing Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of health care-associated infection in nursery units. Overcrowding must be avoided in nurseries, and infants with infectious processes should be isolated. Separate gowns should be worn in caring for each infant in the special care nursery. Soiled linens should be disposed of in an appropriate manner. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Ideally infants should remain with their mothers

Which information regarding to injuries to the infant's plexus during labor and birth is most accurate? a. If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months. b. Erb palsy is damage to the lower plexus. c. Parents of children with brachial palsy are taught to pick up the child from under the axillae. d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A. If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months. If the nerves are stretched with no avulsion, then they should recover completely in 3 to 6 months. However, if the ganglia are completely disconnected from the spinal cord, then the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and the infant will need help from the nurse at the start.

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action at this time? a.Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician b.Continuing to observe and making no changes until the saturations are 75% c.Continuing with the admission process to ensure that a thorough assessment is completed d.Notifying the parents that their infant is not doing well

ANS: A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determining fetal status.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? a.Meconium aspiration, hypoglycemia, and dry, cracked skin b.Excessive vernix caseosa covering the skin, lethargy, and RDS c.Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat d.Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect? a.Hypovolemia and/or shock b.Excessively cool environment c.Central nervous system (CNS) injury d.Pending renal failure

ANS: A Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities. Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to be delivered with respiratory distress.

What is the most important nursing action in preventing neonatal infection? a.Good handwashing b.Isolation of infected infants c.Separate gown technique d.Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

---Which statement regarding human trafficking is correct? a.Human trafficking is a multibillion-dollar business that primarily exists in the United States. b.Victims often experience the Stockholm syndrome. c.Vast majority of the victims are young boys and girls. d.Human trafficking primarily refers to commercial sex work.

ANS: B Although victims of sex trafficking can be young boys and girls, the vast majority are women and girls. They are often lured by false promises, such as a job or marriage, sold by their parents, or kidnapped by traffickers. These individuals are forced into sex work, hard labor, and organ donation. This $32 billion business exists in the United States and internationally. The Stockholm syndrome occurs when the slaves become attached to their enslavers. Health care professionals may interact with victims who are in captivity should they require emergent health care. The nurse is challenged to find an opportunity to speak with the client alone and assess for victimization.

In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement? a.Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). b.Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. c.Know that the greatest catch-up period is between 9 and 15 months postconceptual age. d.Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

----Which trait is least likely to be displayed by a woman experiencing intimate partner violence (IPV)? a.Socially isolated b.Assertive personality c.Struggling with depression d.Dependent partner in a relationship

ANS: B Every segment of society is represented among women who are suffering abuse. However, traits of assertiveness, independence, and willingness to take a stand have been documented as more characteristic of women who are in nonviolent relationships. Women who are financially more dependent have fewer resources and support systems, exhibit symptoms of depression, and are more often seen as victims.

---In 1979, Lenore Walker pioneered the cause of women as victims of violence when she published her book The Battered Woman. While Walker conducted her research she found a similar pattern of abuse among many of the women. This concept is now referred to as the Cycle of Violence. Which phase does not belong in this three-cycle pattern of violence? a. Tension-building state b. Frustration followed by violence c. Acute battering incident d. Kindness and contrite, loving behavior

ANS: B Frustration followed by violence is not part of the Cycle of Violence. Tension-building state is also known as phase I of the cycle. The batterer expresses dissatisfaction and hostility with violent outbursts. The woman senses anger and anxiously tries to placate him. Acute battering incident is phase II of the cycle. It results in the man's uncontrollable discharge of tension toward the woman. Outbursts can last from several hours to several days and may involve kicking, punching, slapping, choking, burns, broken bones, and the use of weapons. Sometimes referred to as the honeymoon, kindness and contrite, loving behavior is the third phase of the cycle. The batterer feels remorseful and apologizes profusely. He tries to help the woman and often showers her with gifts.

1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia? a. Hepatic disease b. Hemolytic disorders c. Postmaturity d. Congenital heart defect

ANS: B Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes. DIF: Cognitive Level: Apply REF: p. 882 TOP: Nursing Process: Diagnosis

---What are the responsibilities of the nurse who suspects or confirms any type of violence against a woman? (Select all that apply.) a.Report the incident to legal authorities. b.Provide resources for domestic violence shelters. c.Call a client advocate who can assist in the client's decision about what actions to take. d.Accurately and concisely document the incident (or findings) in the client's record. e.Reassure and support the client.

ANS: B, C, D, E Domestic violence is considered a crime in all states; however, mandatory reporting remains controversial. Nurses must become knowledgeable on the laws that apply in the state in which they practice. Caring for a client who may be a victim of domestic abuse is an ideal opportunity to provide the woman with information for safe houses or support groups for herself and her children. The nurse may assist in reaching out to a client advocate, which often occurs when potential legal action is taken or if the woman is seeking shelter. Documentation must be accurate and timely to be useful to the client later in court if she chooses to press charges. The primary functions for the nurse are to reassure the client and to provide her with emotional support.

---Documentation of abuse can be useful to women later in court, should they elect to press charges. It is of key importance for the nurse to document accurately at the time that the client is seen. Which entry into the medical record would be the least helpful to the court? a.Photographs of injuries b.Clear and legible written documentation c.Summary of information (e.g., "The client is a battered woman.") d.Accurate description of the client's demeanor

ANS: C A statement such as, "The client is a battered woman" lacks the supporting factual information and will render the report inadmissible. More appropriate documentation would include exact statements from the woman in quotations (e.g., "My husband kicked me in the stomach"). The time and date of the examination should also be included.

12. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

ANS: C Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention. DIF: Cognitive Level: Understand REF: p. 901 TOP: Nursing Process: Planning

---Which statement is the most comprehensive description of sexual violence? a.Sexual violence is limited to rape. b.Sexual violence is an act of force during which an unwanted and uncomfortable sexual act occurs. c.Sexual violence encompasses a number of sexual acts. d.Sexual violence includes degrading sexual comments and behaviors.

ANS: C Sexual violence is a broad term that includes a range of sexual victimization including sexual assault, sexual harassment, and rape. It may include but is not limited to rape. Sexual assault includes unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual acts. It is a component of sexual violence. Unwelcome or degrading e-mail messages, comments, contact, or behavior, such as exhibitionism, that makes any environment feel unsafe is known as sexual harassment.

---In the 1970s, the rape-trauma syndrome (RTS) was identified as a cluster of symptoms and related behaviors observed in the weeks and months after an episode of rape. Researchers identified three phases related to this condition. Which phase is not displayed in a client with RTS? a.Acute Phase: Disorganization b.Outward Adjustment Phase c.Shock/Disbelief: Disorientation Phase d.Long-Term Process: Reorganization Phase

ANS: C Shock, disbelief, or disorientation is a component of the Acute Phase. The rape survivor feels embarrassed, degraded, fearful, and angry. She may feel unclean and want to bathe and douche repeatedly, even though doing so may destroy evidence. The victim relives the scene over and over in her mind, thinking of things she "should have done." During the Outward Adjustment Phase, the victim may appear to have resolved her crisis and return to activities of daily living and work. Other women may move, leave their job, and buy a weapon to protect themselves. Disorientation is a reaction during which the victim may feel disoriented, have difficulty concentrating, or have poor recall. The Long-Term Process is the reorganization phase. This recovery phase may take years and may be difficult and painful.

By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress? a.Decreased respiratory rate b.Bradycardia, followed by an increased heart rate c.Mottled skin with acrocyanosis d.Increased physical activity

ANS: C The infant has minimal-to-no fat stores. During times of cold stress, the skin becomes mottled and acrocyanosis develops, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and to respond quickly if signs and symptoms of cold stress occur. The respiratory rate increases, followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant who is experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, increased physical activity is the natural response to heat loss. However, in a term infant who is experiencing respiratory distress or in a preterm infant, physical activity is decreased.

An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? a.67 mm Hg b.89 mm Hg c.45 mm Hg d.73 mm Hg

ANS: C The laboratory value of PaO2 of 45 mm Hg is below the range for a normal neonate and indicates hypoxia in this infant. The normal range for PaO2 is 60 to 80 mm Hg; therefore, PaO2 levels of 67 and 73 mm Hg fall within the normal range, and a PaO2 of 89 mm Hg is higher than the normal range.

---2. Common characteristics of a potential batterer include (choose all that apply): a. High level of self-esteem b. High frustration tolerance c. Substance abuse problems d. Excellent verbal skills e. Personality disorders

ANS: C, E Substance abuse and personality disorders are often seen in batterers. Typically the batterer has low self-esteem. Batterers usually have a low frustration level (i.e., they lose their temper easily). Batterers characteristically have poor verbal skills and especially can have difficulty expressing their feelings.

When providing an infant with a gavage feeding, which infant assessment should be documented each time? a.Abdominal circumference after the feeding b.Heart rate and respirations before feeding c.Suck and swallow coordination d.Response to the feeding

ANS: D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infant's response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant's response to the feeding, including the attempts to suck.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" How should the nurse respond? a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is prophylactically given to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

C. "Erythromycin is prophylactically given to prevent a gonorrheal infection." With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is given to prevent infection, not for lubrication.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is displaying signs and symptoms of which condition? a. Gonorrhea b. Herpes simplex virus (HSV) infection c. Congenital syphilis d. HIV

C. Congenital syphilis A copper-colored maculopapular rash is indicative of congenital syphilis with lesions that may extend over the trunk and extremities. This rash is not an indication that the neonate has contracted gonorrhea. Rather, the neonate with gonorrheal infection might have septicemia, meningitis, conjunctivitis, and scalp abscesses. Infants affected with the HSV display growth restriction, skin lesions, microcephaly, hypertonicity, and seizures. Typically, the HIV-infected neonate is asymptomatic at birth. Most often the infant develops an opportunistic infection and rapid progression of immunodeficiency

An infant was born 2 hours ago at 37 weeks of gestation and weighs 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of what condition? a. Birth injury b. Hypocalcemia c. Hypoglycemia d. Seizures

C. Hypoglycemia Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

The nurse is evaluating a neonate who was delivered 3 hours ago by vacuum-assisted delivery. The infant has developed a cephalhematoma. Which statement is most applicable to the care of this neonate? a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. c. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. d. Spinal cord injuries almost always result from vacuum-assisted deliveries.

C. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomographic (CT) scans might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. Spinal cord injuries are almost always from breech births; however, spinal cord injuries are rare today because cesarean birth is used for breech presentation

Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing? a. Iron deficiency anemia b. Hyponatremia c. Respiratory distress syndrome d. Sepsis

C. Respiratory Distress Syndrome IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. IDMs are not at risk for anemia, hyponatremia, or sepsis.

The corrected age of an infant who was born at 25 1/7 weeks and is preparing for discharge 124 days past delivery is ______________.

ANS: 42 6/7 weeks The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. For example, an infant born at 32 weeks of gestation 4 weeks ago would now be considered 36 weeks of age. (32 + 4 = 36).

--Historically, what was the justification for the victimization of women? A) Women were regarded as possessions. B) Women were the "weaker sex." C) Control of women was necessary to protect them. D) Women were created subordinate to men.

A) Women were regarded as possessions. - Misogyny, patriarchy, devaluation of women, power imbalance, a view of women as property, gender-role stereotyping, and acceptance of aggressive male behaviors as appropriate contributed and continue to contribute to the subordinate status of women in many of the world's societies. Viewing women as the "weaker sex" is a cultural and modern stereotype that contributes to the victimization of women. Control of women to protect them is another cultural and modern stereotype that contributes to the victimization of women. Yet another cultural stereotype that contributes to the victimization of women is the idea that women were created as subordinate to men.

During a prenatal examination, a woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. The client questions the nurse as to why. What is the nurse's most appropriate response? a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the HIV in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby."

A. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. Approximately 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although cleaning the litter boxes is "just gross," this statement is not appropriate, fails to answer the client's question, and is not the nurse's best response

3. What is the highest priority nursing intervention for an infant born with myelomeningocele? a. Protect the sac from injury. b. Prepare the parents for the childs paralysis from the waist down. c. Prepare the parents for closure of the sac when the child is approximately 2 years of age. d. Assess for cyanosis.

ANS: A A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

---A young woman arrives at the emergency department and states that she thinks she has been raped. She is sobbing and expresses disbelief that this could happen because the man was her best friend. In an effort to calm the client in order to perform a thorough assessment and physical examination, the nurse acknowledges the client's fear and anxiety and tells her: a. "Rape is not limited to strangers and frequently occurs by someone who is known to the victim." b. "I would be very upset if my best friend did that to me; that is very unusual." c."You must feel very betrayed. In what way do you think you might have led him on?" d."This does not sound like rape. Didn't you just change your mind about having sex after the fact?"

ANS: A Acquaintance rape involves individuals who know one another. Sexual assault occurs when the trust of a relationship is violated. Victims may be less prone to recognize what is happening to them because the dynamics are different from those of stranger rape. It is not at all unusual for the victim to know and trust the perpetrator. Stating that the woman might have led the man to attack her indicates that the sexual assault was somehow the victim's fault. This type of mentality is not constructive. Nurses must first reflect on their own feelings and learn to be unbiased when dealing with victims. A statement of this type can be very psychologically damaging to the victim. Nurses must display compassion by first believing what the victim states. The nurse is not responsible for deciphering the facts involving the victim's claim.

2. Which infant is most likely to express Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor b. Infant who is Rh negative and a mother who is Rh negative c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor d. Infant who is Rh positive and a mother who is Rh positive

ANS: A If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive. DIF: Cognitive Level: Understand REF: p. 883 TOP: Nursing Process: Planning

10. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn? a. Mild cases involve a single surgical procedure. b. Infant should be circumcised. c. Repair is performed as soon as possible after birth. d. No correlation exists between hypospadia and testicular cancer.

ANS: A Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation. DIF: Cognitive Level: Apply REF: p. 902

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a."Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b."The drug keeps your baby from requiring too much sedation." c."Surfactant is used to reduce episodes of periodic apnea." d."Your baby needs this medication to fight a possible respiratory tract infection."

ANS: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

6. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct? a. Cardiac disease may demonstrate signs and symptoms of respiratory illness. b. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress. c. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage. d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

ANS: A The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

---When the nurse is alone with a battered client, the client seems extremely anxious and says, "It was all my fault. The house was so messy when he got home, and I know he hates that." What is the most suitable response by the nurse? a."No one deserves to be hurt. It's not your fault. How can I help you?" b."What else do you do that makes him angry enough to hurt you?" c."He will never find out what we talk about. Don't worry. We're here to help you." d."You have to remember that he is frustrated and angry so he takes it out on you."

ANS: A The nurse should stress that the client is not at fault. Asking what the client did to make her husband angry is placing the blame on the woman and would be an inappropriate statement. The nurse should not provide false reassurance. To assist the woman, the nurse should be honest. Often the batterer will find out about the conversation.

3. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Positive Ortolani click b. Unequal gluteal folds c. Negative Babinski sign d. Trendelenburg sign e. Telescoping of the affected limb

ANS: A, B A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH. DIF: Cognitive Level: Apply REF: p. 900 TOP: Nursing Process: Planning

Which risk factors are associated with NEC? (Select all that apply.) a.Polycythemia b.Anemia c.Congenital heart disease d.Bronchopulmonary dysphasia e.Retinopathy

ANS: A, B, C Risk factors for NEC include asphyxia, RDS, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC

---A thorough abuse assessment screen should be completed on all female clients. This screen should include which components? (Select all that apply.) a.Asking the client if she has ever been slapped, kicked, punched, or physically hurt by her partner b.Asking the client if she is afraid of her partner c.Asking the client if she has been forced to perform sexual acts d.Diagramming the client's current injuries on a body map e.Asking the client what she did wrong to elicit the abuse

ANS: A, B, C, D Asking the client if she has been slapped, kicked, punched, or physically hurt by her partner, if she is afraid of her partner, or if she has been forced to perform sexual acts are questions that should be posed to all clients. If any physical injuries are present, then they should be marked on a form that indicates their locations on the body. Implying that a client did something wrong can be very emotionally damaging. Many victims of violence are not aware that they are in an abusive relationship. They may not respond to questions about abuse. Using general descriptive words such as "slap," "kick," or "punch" to elicit information is best.

---Which nursing diagnosis would be most applicable for battered women? Choose all that apply. a. Loss of trust b. Ineffective family coping c. Situational low self-esteem d. Risk for self-directed violence e. Enhanced communication

ANS: A, B, C, D Loss of trust, ineffective family coping, situational low self-esteem, and risk for self-directed violence are potential nursing diagnoses associated with battered women. A more appropriate nursing diagnosis for this client would be impaired communication.

1. The nurse who is evaluating the client for potential abuse should be aware that intimate partner violence includes (choose all that apply): a. Physical abuse b. Sexual abuse c. Emotional abuse d. Psychologic abuse e. Economic abuse

ANS: A, B, C, D, E Physical, sexual, emotional, psychologic, and economic abuse can be factors in intimate partner violence.

---The nurse who is evaluating the client for potential abuse should be aware that IPV includes a number of different forms of abuse, including which of the following? (Select all that apply.) a.Physical b.Sexual c.Emotional d.Psychologic e.Financial

ANS: A, B, D, E Physical, sexual, financial, and psychologic abuse can all be components in a relationship with IPV. Emotional abuse is a form of psychologic abuse.

1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.) a. Alcohol consumption b. Female gender c. Use of some anticonvulsant medications d. Maternal cigarette smoking e. Antibiotic use in pregnancy

ANS: A, C, D Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate. DIF: Cognitive Level: Understand REF: p. 895 TOP: Nursing Process: Planning

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is similar to that of a full-term baby. These infants are at increased risk for which conditions? (Select all that apply.) a.Problems with thermoregulation b.Cardiac distress c.Hyperbilirubinemia d.Sepsis e.Hyperglycemia

ANS: A, C, D Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is adequately feeding before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with "ineffective coping, related to"? a.Severe immaturity b.Environmental stress c.Physiologic distress d.Behavioral responses

ANS: B "Ineffective coping, related to environmental stress" is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infant's behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response.

NEC is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. Which intervention has the greatest effect on lowering the risk of NEC? a.Early enteral feedings b.Breastfeeding c.Exchange transfusion d.Prophylactic probiotics

ANS: B A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances the maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn disease, and celiac illness. The NICU nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

9. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process? a. Maternal diabetes b. Maternal folic acid deficiency c. Socioeconomic status d. Maternal use of anticonvulsant

ANS: B All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

The nurse suspects that a client who comes to the maternity clinic for a pregnancy test is in an abusive relationship. The nurse includes the abuse assessment screen as part of the assessment. Although the woman was very emotional and hesitant in responding to the questions, verbally she denied abuse as being a problem. While waiting for the results of the pregnancy test, the nurse decides to teach the client about partner abuse anyway. The rationale for the nurse's decision is that all women should be informed about: a. The nurse's ethical responsibility to protect clients b. The cycle of violence, which continues and escalates over time once it begins c. Women's legal right not to be controlled by men d. The masochistic nature of women who stay in abusive relationships

ANS: B Because of the cycle of violence and the loving respite phase, denial is a coping mechanism often used by battered women. During pregnancy the nurse should assess for abuse at each prenatal visit and on admission to labor. Although the nurse may feel an ethical responsibility to protect the client, it is not the best rationale for the nurse's behavior. Although women have a right not to be controlled by men, it is not the reason the nurse should continue the teaching with this client. The belief that women are masochistic is simply a myth.

---5. Intimate partner violence (IPV) is seen in all races, ethnicities, religions, and socioeconomic backgrounds. Which statement is most accurate regarding the reporting of IPV in the United States? a. Asian women report more IPV than do other minority groups. b. Caucasian women report less IPV than do non-Caucasians. c. Native-American women report IPV at a rate similar to other groups. d. African-American women are less likely to report IPV than Caucasian women.

ANS: B Caucasian women report less IPV than other ethnic groups. Asian women report significantly less IPV than do other racial groups. Native-American and Alaska Native women report significantly more IPV than do women of any other racial background. African-American women tend to report violence at a slightly higher rate than Caucasian women.

With regard to infants who are SGA and intrauterine growth restriction (IUGR), the nurse should be aware of which information? a.In the first trimester, diseases or abnormalities result in asymmetric IUGR. b.Infants with asymmetric IUGR have the potential for normal growth and development. c.In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. d.Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; infants who are SGA have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a.NEC b.ROP c.BPD d.Intraventricular hemorrhage (IVH)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from the rupture of the fragile blood vessels in the ventricles of the brain and is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition? a.Hypertonia, tachycardia, and metabolic alkalosis b.Abdominal distention, temperature instability, and grossly bloody stools c.Hypertension, absence of apnea, and ruddy skin color d.Scaphoid abdomen, no residual with feedings, and increased urinary output

ANS: B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

----A woman who is 6 months pregnant has sought medical attention, saying she fell down the stairs. What scenario would cause an emergency department nurse to suspect that the woman has been a victim of IPV? a.The woman and her partner are having an argument that is loud and hostile. b.The woman has injuries on various parts of her body that are in different stages of healing. c.Examination reveals a fractured arm and fresh bruises. D.She avoids making eye contact and is hesitant to answer questions

ANS: B The client may have multiple injuries in various stages of healing that indicates a pattern of violence. An argument is not always an indication of battering. A fractured arm and fresh bruises could be caused by the reported fall and do not necessarily indicate IPV. It may be normal for the woman to be reticent and have a dull affect.

A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse's most appropriate action? a.Wait quietly at the newborn's bedside until the parents come closer. b.Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. c.Leave the parents at the bedside while they are visiting so that they have some privacy. d.Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.

ANS: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

---Nurses must remember that pregnancy is a time of risk for all women. Which condition is likely the biggest risk for the pregnant client? a. Preeclampsia b. Intimate partner violence (IPV) c. Diabetes d. Abnormal Pap test

ANS: B The prevalence of IPV during pregnancy is estimated at 4% to 8% of all pregnant women. The risk for IPV and even IPV-related homicide is more common than all of the other pregnancy-related conditions. Although preeclampsia poses a risk to the health of the pregnant client, it is less common than IPV. Gestational diabetes continues to be a complication of pregnancy; however, it is less common than IPV during pregnancy. Some women are at risk for an abnormal Pap screening during pregnancy. This finding is not as common as IPV.

---Nurses who provide care to victims of IPV should be keenly aware of what? a. Relationship violence usually consists of a single episode that the couple can put behind them b. Violence often declines or ends with pregnancy c. Economic coercion is considered part of IPV d. Battered women generally are poorly educated and come from a deprived social background

ANS: C Economic coercion accompanies physical assault and psychologic attacks. IPV almost always follows an escalating pattern. It rarely ends with a single episode of violence. IPV often begins with and escalates during pregnancy. It may include both psychologic attacks and economic coercion. Race, religion, social background, age, and education level are not significant factors in differentiating women at risk.

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a.Rapid bolusing of the entire amount in 15 minutes b.Warm cloths to the abdomen for the first 10 minutes c.Slow, small, warm bolus feedings over 30 minutes d.Cold, medium bolus feedings over 20 minutes

ANS: C Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents? a.Infants stay in the NICU until they are ready to go home. b.Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. c.Parents of high-risk infants need special support and detailed contact information. d.If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

ANS: C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Simply because high-risk infants are eventually discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

11. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching? a. Apply lotion or powder to minimize skin irritation. b. Remove the harness several times a day to prevent contractures. c. Return to the clinic every 1 to 2 weeks. d. Place a diaper over the harness, preferably using an absorbent disposable diaper.

ANS: C Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. Which statement regarding this intervention is most appropriate? a.Kangaroo care was adopted from classical British nursing traditions. b.This intervention helps infants with motor and CNS impairments. c.Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. d.This intervention gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

For clinical purposes, the most accurate definition of preterm and postterm infants is defined as what? a.Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) b.Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA c.Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth d.Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of the size for gestational age.

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response? a."Your baby will develop exactly like your first child." b."Your baby does not appear to have any problems at this time." c."Your baby will need to be corrected for prematurity." d."Your baby will need to be followed very closely."

ANS: C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

---The primary theme of the feminist perspective on violence against women recognizes the: a. Role of testosterone as the underlying cause of men's violent behavior b. Basic human instinctual drive toward aggression c. Dominance and coercive control over women by men d. Cultural norm of violence in Western society

ANS: C The contemporary social view of violence is derived from the feminist theory. With the primary theme of male dominance and coercive control, this view enhances our understanding of all forms of violence against women, including wife battering, stranger and acquaintance rape, incest, and sexual harassment in the workplace. The role of testosterone as an underlying cause of men's violent behavior is not associated with the feminist perspective of violence against women. The basic human instinctual drive toward aggression is not associated with the feminist perspective. The cultural norm of violence in Western society is not associated with the feminist perspective regarding violence against women.

---Intervention for the sexual abuse survivor often is not attempted by maternity and women's health nurses because of the concern about increasing the distress of the woman and the lack of expertise in counseling. What initial intervention is appropriate and most important in facilitating the woman's care? a. Initiating a referral to an expert counselor b. Setting limits on what the client discloses c. Listening and encouraging therapeutic communication skills d. Acknowledging the nurse's discomfort to the client as an expression of empathy

ANS: C The survivor needs support on many different levels, and a women's health nurse may be the first person to whom she relates her story. Therapeutic communication skills and listening are initial interventions. Referring this client to a counselor is an appropriate measure but not the most important initial intervention. A client should be allowed to disclose any information she feels the need to discuss. As a nurse you should provide a safe environment in which she can do so. Either verbal or nonverbal shock and horror reactions from the nurse are particularly devastating. Professional demeanor and professional empathy are essential.

13. Which statement regarding hemolytic diseases of the newborn is most accurate? a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions are frequently required in the treatment of hemolytic disorders. d. The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.

ANS: D An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

7. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform? a. Be able to perform the Ortolani and Barlow tests. b. Teach double or triple diapering for added support. c. Explain to the parents the need for serial casting. d. Carefully monitor infants for DDH at follow-up visits.

ANS: D Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH. DIF: Cognitive Level: Apply REF: p. 899 TOP: Nursing Process: Planning

---Women with severe and persistent mental illness are likely to be more vulnerable to being involved in controlling and/or violent relationships; however, many women develop mental health problems as a result of long-term abuse. Which condition is unlikely to be a psychologic consequence of continued abuse? a.Substance abuse b.Posttraumatic stress disorder (PTSD) c.Eating disorders d.Bipolar disorder

ANS: D Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to abuse. Substance abuse is a common method of coping with long-term abuse. The abuser is also more likely to use alcohol and other chemical substances. PTSD is the most prevalent mental health sequela of long-term abuse. The traumatic event is persistently re-experienced through distress recollection and dreams. Eating disorders, depression, psychologic-physiologic illness, and anxiety reactions are all mental health problems associated with repeated abuse.

Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing? a.Suffering from sleep or wakeful apnea b. Experiencing severe swings in blood pressure c.Trying to maintain a neutral thermal environment d.Breathing in a respiratory pattern common to premature infants

ANS: D Breathing in a respiratory pattern is called periodic breathing and is common to premature infants. This pattern may still require nursing intervention of oxygen and/or ventilation. Apnea is the cessation of respirations for 20 seconds or longer and should not be confused with periodic breathing.

Which clinical findings would alert the nurse that the neonate is expressing pain? a.Low-pitched crying; tachycardia; eyelids open wide b.Cry face; flaccid limbs; closed mouth c.High-pitched, shrill cry; withdrawal; change in heart rate d.Cry face; eyes squeezed; increase in blood pressure

ANS: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

4. The primary responsibility of the nurse who suspects or confirms any type of violence against a woman is: a. Report the incident to legal authorities b. Provide information to social services c. Call a client advocate who can assist in the client's decision making about what action to take d. Document the incident (or findings) accurately and concisely in the client's record

ANS: D Documentation can be useful to women later in court if they choose to press charges. Although many states have mandatory reporting laws, the primary responsibility of the nurse is to document the incident and findings. Social services is called only if a child also is a victim of violence or had witnessed the violence. A client advocate usually is notified when legal action is to be taken or if the woman is seeking shelter. The nurse may assist in this endeavor, but it is not the first action to be taken.

4. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia? a. Risk for impaired parent-infant attachment b. Imbalanced nutrition, related to less than body requirements c. Risk for infection d. Impaired gas exchange

ANS: D Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

---The nurse's best measure of evaluating care of a rape victim is that: a. All legal evidence is preserved during the physical examination b. The victim appreciates the legal information but decides not to pursue legal proceedings c. The victim states that she is going to advocate against sexual violence d.The victim leaves the health care facility without feeling revictimized

ANS: D Nurses can assist clients through an examination that is as nontraumatic as possible with kindness, skill, and empathy. The initial care of the victim affects her recovery and decision to receive follow-up care. Preservation of all legal evidence is very important; however, this may not be the best measure in terms of evaluating care of a rape victim. Offering legal information is not the best measure of evaluating the care that this victim received. The victim may well decide not to pursue legal proceedings. Advocating against sexual violence may be extremely therapeutic for the client after her initial recovery. This is not a measure of evaluating her care.

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a."Parents are not allowed to hold their infants who are dependent on oxygen." b."You may only hold your baby's hand during the feeding." c."Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." d."You may hold your baby during the feeding."

ANS: D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? a.Few blood vessels visible through the skin b.More subcutaneous fat c.Well-developed flexor muscles d.Greater surface area in proportion to weight

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

8. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy? a. High-pitched cry b. Severe muscle spasms (opisthotonos) c. Fever and seizures d. Hypotonia, lethargy, and poor suck

ANS: D The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a.Delayed growth and development b.Ineffective thermoregulation c.Ineffective infant feeding pattern d.Risk for infection

ANS: D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant's care? a. Prone positioning facilitates bone alignment. b. No special treatment is necessary. c. Parents should be taught range-of-motion exercises. d. The shoulder should be immobilized with a splint.

B. No special treatment is necessary. Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. Performing range-of-motion exercises on the infant is not necessary. A fractured clavicle does not require immobilization with a splint

The nurse should be cognizant of which condition related to skeletal injuries sustained by a neonate during labor or childbirth? a. Newborn's skull is still forming and fractures fairly easily. b. Unless a blood vessel is involved, linear skull fractures heal without special treatment. c. Clavicle fractures often need to be set with an inserted pin for stability. d. Other than the skull, the most common skeletal injuries are to leg bones.

B. Unless a blood vessel is involved, linear skull fractures heal without special treatment. Approximately 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. What is the first step in the provision of care for the infant? a. Pharmacologic treatment b. Reduction of environmental stimuli c. Neonatal abstinence syndrome (NAS) scoring d. Adequate nutrition and maintenance of fluid and electrolyte balance

C. Neonatal abstinence Syndrome (NAS) Scoring NAS describes the cohort of symptoms associated with drug withdrawal in the neonate. The NAS system evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal (GI) disturbances. This evaluation tool enables the health care team to develop an appropriate plan of care. The infant is scored throughout his or her length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of the withdrawal symptoms, which are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage

For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care? a. Administering chloral hydrate for sedation b. Feeding every 4 to 6 hours to allow extra rest between feedings c. Snugly swaddling the infant and tightly holding the baby d. Playing soft music during feeding

C. Snugly swaddling the infant and tightly holding the baby. The infant should be snugly wrapped to reduce self-stimulation behaviors and to protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because stimulation will increase activity and potentially increase CNS irritability.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). What is the nurse's first priority? a. Leave the infant in the room with the mother. b. Immediately take the infant to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia

D. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia Regardless of gestational age, this infant is macrosomic (defined as fetal weight more than 4000 g) and is at high risk for hypoglycemia, which affects many macrosomic infants. Blood glucose levels should be frequently monitored, and the infant should be closely observed for signs of hypoglycemia. Close observation can be achieved in the mother's room with nursing interventions. However, depending on the condition of the infant, observation may be more appropriate in the nursery

What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection b. Tuberculosis c. Candidiasis d. Group B streptococci (GBS) infection

D. Group B Stretococci (GBS) infection Penicillin has significantly decreased the incidence of GBS infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and in Canada. Candidiasis is a fairly benign fungal infection

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress? a. Hypoglycemia b. Phrenic nerve injury c. Respiratory distress syndrome d. Sepsis

D. Sepsis The prolonged rupture of membranes and the tachypnea (before and after birth) suggest sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually the result of traction on the neck and arm during childbirth and is not applicable to this situation. The earliest signs of sepsis are characterized by lack of specificity (e.g., lethargy, poor feeding, irritability), not respiratory distress syndrome.

Human immunodeficiency virus (HIV) may be transmitted perinatally or during the postpartum period. Which statement regarding the method of transmission is most accurate? a. Only in the third trimester from the maternal circulation b. From the use of unsterile instruments c. Only through the ingestion of amniotic fluid d. Through the ingestion of breast milk from an infected mother

D. Through the ingestion of breast milk from an infected mother. Postnatal transmission of the HIV through breastfeeding and breast milk may occur. Transmission of the HIV from the mother to the fetus may occur through the placenta at various gestational ages. Transmission of the HIV from the use of unsterile instruments is highly unlikely; most health care facilities must meet sterility standards for all instrumentation.

5. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis? a. Edema b. Immature red blood cells c. Enlargement of the heart d. Ascites

Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.

2. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.) a. Phenylketonuria (PKU) b. Galactosemia c. Hemoglobinopathy d. Cytomegalovirus (CMV) e. Rubella

NS: A, B, C PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus. DIF: Cognitive Level: Understand REF: p. 904 TOP: Nursing Process: Planning