Exam 5

The most important reason to protect the preterm infant from cold stress is that • a.it could make respiratory distress syndrome worse. b.shivering to produce heat may use up too many calories. c.a low temperature may make the infant less able to digest nutrients. d.cold decreases circulation to the extremities.

ANS A it could make respiratory distress syndrome worse.

A first-time father is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, which point should be included? • a.Physiologic jaundice occurs during the first 24 hours of life. b.Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c.The bilirubin levels of physiologic jaundice peak at 5 to 7 mg/dL between the second and fourth days of life. d.This condition is also known as breast milk jaundice.

ANS C The bilirubin levels of physiologic jaundice peak at 5 to 7 mg/dL between the second and fourth days of life.

Which situation would require the administration of in(D) immune globulin? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative

ANS: A An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.

Which intervention will increase the effectiveness in reducing the indirect bilirubin in an affected newborn? a. Turn the infant every 2 hours. b. Place eye patches on the newborn. c. Wrap the infant in triple blankets to prevent cold stress. d. Increase the oral intake of water between and before feedings.

ANS: A Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from accessing the skin and being effective. The infant should be uncovered and unclothed. It is important to increase oral feedings, although water should not necessarily be given. Breast milk or formula will increase the reduction of bilirubin.

The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurse's priority action? a. Massage the fundus of the uterus. b. Assist the patient out of bed to void. c. Increase the infusion of oxytocin (Pitocin). d. Ask another nurse to bring in a straight catheter tray.

ANS: A If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment, while the other hand gently but firmly massages the fundus in a circular motion. Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. If the uterus does not remain contracted as a result of uterine massage or if the fundus is displaced, the bladder may be distended. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate or catheterize her to correct uterine atony caused by bladder distention. Note the urine output. When the fundus is boggy, begin uterine massage. Check the woman's bladder for distention and have her empty it if necessary. If she is not able to void and the bladder is distended, catheterize the patient. Weigh blood-soaked pads.

Which patient data received during report should the nurse recognize as being at risk for postpartum complications? a. Gravida 5, para 5 b. Labor duration of 4 hours c. Infant weight greater than 3800 g d. Epidural anesthesia for labor and birth

ANS: A Multiparity (five or more deliveries) is a risk factor for postpartum uterine atony and hemorrhage. A labor duration of 4 hours is not a risk factor because it is not a precipitate labor and birth (less than 3 hours), infant weight of 3800 g is not a risk factor because the infant is not macrosomic, and epidural anesthesia is not a risk factor because epidural anesthesia does not affect uterine contractions.

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.

ANS: A Persistent pulmonary hypertension has been associated with hypoxemia and acidosis as a result of the aspiration of meconium. Bronchopulmonary dysplasia is a complication of the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is the result of inadequate absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.

Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.) a. Insufficient emptying b. Feeding every 2 hours c. Supplementing feedings d. Blisters on both nipples e. Alternating breastfeeding positions

ANS: A, C, D Mastitis may develop because of stasis of milk, inadequate emptying of the breast, skipped feedings, and introduction of bacteria through injured areas of the nipple. Feeding every 2 hours and alternating breastfeeding positions are both interventions that promote emptying of the breasts and support successful breastfeeding.

The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include which of the following? (Select all that apply.) a. Anemia b. Dehydration c. Exhaustion d. Postpartum infection e. Failure to attach to her infant

ANS: A, C, D, E Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated. Exhaustion is common after hemorrhage. It may take the new patient weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and the attachment processes. The patient is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection. The excessive blood loss that this patient has experienced is likely to lead to risk for infection rather than dehydration. It is important that all mothers be educated about adequate fluid intake after birth.

Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? {Select all that apply.) a. Sepsis b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress e. Problems with thermoregulation

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

The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex

ANS: A,B,E Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera.

The nurse suspecting a uterine infection in a postpartum patient should assess the a. episiotomy site. b. odor of the lochia. c. abdomen for distention. d. pulse and blood pressure.

ANS: B An abnormal odor of the lochia indicates infection in the uterus. The infection may move to the episiotomy site if proper hygiene is not followed. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and will be more specific.

The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 10 to 15 cm (4- to 6-inch) stain on the peripad c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad d. Less than a I-inch stain on the peripad

ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: • Scant-less than 2.5 cm (I-inch) stain on the peripad • Light-less than a 10 cm (4 inch) stain • Moderate-less than a 15 cm (6 inch) stain • Heavy-saturated peripad • Excessive-saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.

Infants who develop cephalohematoma are at an increased risk for a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caputisanedematous areaontheheadfrompressure againstthecervix.Erythema toxicum is a benign rash of unknown cause that is sometimes referred to as"fleabite rash."

A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely? a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels

ANS: B Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infant's body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface.

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? a. Radiation b. Conduction c. Convection d. Evaporation

ANS: B Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.

The nurse understands that late postpartum hemorrhage may be prevented by a. manually removing the placenta. b. inspecting the placenta after birth. c. administering broad-spectrum antibiotics. d. pulling on the umbilical cord to hasten the birth of the placenta.

ANS: B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

The patient who is being treated for endometritis is placed in the Fowler position because this position a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.

ANS: B Lochia and infectious material are eliminated by gravity drainage. The Fowler position may not be the position of comfort, but it does allow for drainage. Good hygiene practice aids in preventing the spread of infection to the urinary tract. This position aids in the drainage of lochia and infectious material.

Following the vaginal birth of a macrosomic infant, the nurse should evaluate the infant for a. hyperglycemia. b. clavicle fractures. c. hyperthermia. d. an increase in red blood cells.

ANS: B Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to become hypoglycemic and would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice a. may result in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.

ANS: B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. This type ofjaundice may lead to kernicterus; however, screening and appropriate treatment needs to take place in a time sensitive manner in order to prevent kernicterus. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Nonphysiologic jaundice is caused by an underlying condition, such as Rh incompatibility.

A patient has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The patient now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to a. evaluate intake and output of the past 12 hours following birth. b. initiate a rapid response intervention. c. obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs). d. reposition the patient and reassess in 15 minutes. Initiate frequent vital sign assessments.

ANS: B Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent patient history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the patient's complaints of difficulty breathing suggest that the patient is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the patient can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the patient, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 21°C (70°F). b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.

ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection.

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. prevent rapid emptying of the bilirubin from the bowel.

ANS: B Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant's system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. Breast milk or formula is more effective in promoting stooling and removal of bilirubin.

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.

A patient with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? a. Organisms will be inactivated by gastric acid. b. Organisms that cause mastitis are not passed through the milk. c. The infant is not susceptible to the organisms that cause mastitis. d. The infant is protected from infection by immunoglobulins in the breast milk.

ANS: B The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infant's gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections; however, this infection is in the breast tissue and is not excreted in the breast milk. The patient is just producing the immunoglobulin from this infection, so it is not available for the infant.

Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K? a. "The nurse will draw blood to determine if vitamin K is needed." b. "Vitamin K prevents the possibility of bleeding problems in my baby." c. "My baby will receive medication by mouth when the nurse administers the vitamin K." d. "Vitamin K will be administered shortly after birth, generally within the first hour."

ANS: B This indication is the reason for vitamin K administration. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Vitamin K is not routinely given by mouth. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding shortly after birth.

An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as a. SGA. b. VLBW. c. ELBW. d. low birth weight at term.

ANS: B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. This option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks' gestation.

The nurse is calling a new mother to schedule a routine home visit planned for 48 to 72 hours after discharge. What is the nurse's priority question to help determine the best time for the visit? a. "When will the baby's father be home?" b. "Do you plan on having any visitors in the day or two?" c. "At approximately what time do you think you will be nursing your baby?" d. "When will your home be presentable enough for me to come and visit?"

ANS: C A feeding session should be observed, especially if the mother is breastfeeding. Establishment of milk supply, adequacy of the breast milk, and general support are important topics to discuss for the mother who is breastfeeding for the first time. During the home visit, the nurse performs a physical examination of the mother and infant. Family adaptation to the addition of a new member and the adequacy of the mother's support system is also assessed. Cleanliness of the home environment is only a concern when the baby's health is at risk.

An hour after birth, the nurse assesses a newborn's temperature and notes that it is 36.2°C (97.2°F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurse's next action? a. Take the infant's temperature rectally. b. Ask the father to test the water to determine if it is too hot. c. Delay the bath until the newborn's temperature is above 36.7°C (98°F). d. Explain to the new parents that no soap should be used to cleanse the eyes.

ANS: C A temperature of 36.7°C (98°F) or higher is often used to determine when to bathe the infant. The infant can lose heat in the bath through the process of evaporation. Rectal temperatures are avoided because they can traumatize the rectal mucosa. The water temperature should be approximately 38 to 40°C (100.4 to 104°F). The nurse should determine if the bath water is the correct temperature to avoid scalding the newborn. Explain the process of giving a bath during the procedure. Informing the parents before the procedure may result in loss of information.

The nurse is explaining the procedure of newborn screening to parents prior to discharge. Which statement by the parents indicates a need for further teaching? a. "We understand the tests are performed at 24 to 48 hours." b. "We're glad all the tests can be done on one blood sample." c. "We wish the tests would screen for congenital hypothyroidism, it runs in our family." d. "We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks."

ANS: C Common disorders often included in newborn screening are phenylketonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia, and congenital adrenal hyperplasia. The parents require further teaching if they suggest that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn screening requires a blood sample taken from the infant's heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing.

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin.

ANS: C Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble.

The nurse observes the patient as she ambulates to the bathroom. Which clinical finding might indicate development of a DVT (deep vein thrombosis)? a. Slow gait b. Shuffling gait c. Stiffness of right leg d. Leans on husband for support

ANS: C Deep vein thrombosis may cause pain on ambulation and stiffness of the affected leg. A slow gait, shuffling gait, and needing ambulatory support are common observations of the postpartum patient because of weakness and discomfort of the perineum.

Which measure may prevent mastitis in a breastfeeding patient? a. Wearing a tight-fitting bra. b. Applying ice packs prior to feeding. c. Initiating early and frequent feedings. Nursingtheinfantfor5minutesoneachbreast.

ANS: C Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the milk. A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.

The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38°C (100.4°F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

ANS: C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38°C (100.4°F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

A postpartum patient has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen? a. Fresh fruits b. Milk c. Lentils d. Soda

ANS: C Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.

Which statement regarding large-for-gestational age (LGA) infants is most accurate? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome is the most common complication.

ANS: C Hypoglycemia,polycythemia,andbirthinjuries areallcommon inLGAinfants.LGAinfants aredeterminedbytheirweightcomparedtotheirage.Theyareabovethe90thpercentileon gestationalgrowthcharts.Postmaturitysyndromeisnotanexpectedcomplication withLGA infants.

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn? a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate.

ANS: C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.

The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back. What should the nurse do next? a. Report the incident to the social services department. b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. Report to oncoming staff that the mother is probably not a good disciplinarian.

ANS: C The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate. This is normal for an adjusting family.

As you receive a report, which assessment finding should you recognize as an indication of a vaginal laceration? a. Fundus firm at the umbilicus b. Pulse of 90 bpm, blood pressure of 110/78 mm Hg c. Bright red continuous trickle of blood from vagina d. Patient requested pain medication twice during last shift

ANS: C Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red color of lochia; a firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being medicated twice in one shift are common findings in the postpamim patient.

1. A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment? a. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b. Make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c. Include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role. d. Observe the son's reaction to the baby and let him decide when he wants to be introduced to his new sibling.

ANS: C Providing the older son with a special role designation and involving him in the care of the baby will facilitate sibling attachment. Spending individual time with the older child is recommended but will not facilitate sibling attachment. Although the older child should be supervised because of his age in terms of infant safety, this level of overprotection may inhibit sibling attachment. Observation of his behavior may be warranted; however, the age of the child (2 years) does not warrant this type of control.

Which statement regarding newborns classified as small for gestational age (SGA) is accurate? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. They are below the tenth percentile on gestational growth charts. d. Placental malfunction is the only recognized cause of this condition.

ANS: C SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are classified as preterm. There are many factors that contribute to the development of an SGA infant, not just placental malfunction.

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K? a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It is responsible for the breakdown of bilirubin and the prevention of jaundice.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. The platelet count in term of newboms is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors.

Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample c. Infant bilirubin level d. Maternal blood type

ANS: C The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infant's bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice.

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patient's chart.

ANS: C The lochia of the cesarean birth mother will go through the same phases as that of the woman who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss; but, this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is a. soft and supple skin. b. a hematocrit level of 55%. c. lack of subcutaneous fat. d. an abundance of vernix caseosa.

ANS: C This post-term infant has actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.

How can nurses prevent evaporative heat loss in the newborn? a. Placing the baby away from the outside wall and the windows b. Keeping the baby out of drafts and away from air conditioners c. Drying the baby after birth and wrapping the baby in a dry blanket d. Warming the stethoscope and nurse's hands before touching the baby

ANS: C Wet linens or wet clothes can cause heat loss by evaporation. Radiation heat loss is caused by placing the baby near cold surfaces or equipment. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. Conduction heat loss occurs when the baby comes into contact with cold objects or surfaces.

A positive sign of thrombophlebitis includes a. visible varicose veins. b. positive Homans sign. c. pedal edema in the affected leg. localtenderness, heat,andswelling.

ANS: D Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the patient to thrombophlebitis; however, are not an indication of thrombophlebitis. A positive Homans sign is indicative of deep vein thrombosis (DVT).

To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

ANS: D Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.

The infant's heat loss immediately at birth is predominantly from a. radiation. b. conduction. c. convection. d. evaporation.

ANS: D Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct contact with the infant. Conduction occurs when the infant comes into contact with a cold surface. The crib should be preheated to prevent this from occurring. Convection occurs when heat is transferred to the air surrounding the infant.

Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

ANS: D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.

If a DVT (deep vein thrombosis) is suspected, the nurse should a. perform a Homans sign on the affected leg. b. dorsiflex the foot of the affected leg. c. palpate the affected leg for edema and pain. d. place the patient on bed rest, with the affected leg elevated.

ANS: D Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.

Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infant's weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. Three successive temperature measurements were 36.1°C, 35.5°C, and 36.1°C (97, 96, and 97°F).

ANS: D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? a. Dry the baby off. b. Turn up the temperature in the patient's room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patient's abdomen after the cord is cut.

ANS: D Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mother's skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patient's room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the baby's temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time? a. "When did these symptoms begin?" b. "Sounds like normal postpartum depression." c. "Are you having trouble getting enough sleep?" d. "Are you able to get out of bed and provide care for your baby?"

ANS: D Postpartum blues mustbedistinguished from postpartum depression and postpartum psychosis, which aredisabling conditions and require therapeutic management forfull recovery. Nurses need toassess thedepression toascertain ifsheisunable tocope with daily life. Postpartum blues areself-limiting and frequently occur bythefifth postpartum day and resolve in2 weeks. The response "Sounds like postpartum depression" does not offer the patient any help orencouragement through this challenging time. Asking ifshe isgetting enough sleep does not add totheassessments already identified inthestem. Enough information existstodetermine thatshehasthesignsandsymptoms ofpostpartum blues.The nurse must differentiate between postpartum blues and depression

Which infant has the lowest risk of developing high levels of bilirubin? a. The infant who developed a cephalohematoma b. The infant who was bruised during a difficult birth c. The infant who uses brown fat to maintain temperature The infant who is breastfed during the first hour of life.

ANS: D The infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation. Cephalohematomas will release bilirubin into the system as the red blood cells die off. Bruising will release more bilirubin into the system. Brown fat is normally used to produce heat in the newborn.

Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is optimal for the newborn? a. Deltoid muscle b. Gluteal muscle c. Rectus femoris muscle d. Vastus lateralis muscle

ANS: D The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections.

An infant's temperature is recorded at 36°C (96.8°F) during the morning assessment. Which action should the nurse take? a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water. d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.

ANS: D This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR; however, this is not the priority intervention. Unwrapping the infant would lead to further compromise and additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which may accompany hypothermia.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a. uterine atony. b. perineal hematoma. c. infection of the uterus. d. lacerations of the genital tract.

ANS: D Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations will not be affected by uterine contraction. The fundus would be boggy with a clinical finding of uterine atony. A hematoma would occur internally with swelling and discoloration. With an infection of the uterus, there would be an odor to the lochia and systemic symptoms such as fever and malaise.

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity related to diarrhea as a result of phototherapy c. Fluid volume deficit related to phototherapy treatment d. Knowledge deficit (parents) related to initiation of medical therapy

ANs: c Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for these parents; but, physiologic needs take precedence at this time.

The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. Rotate the hips in an upward and outward direction.

a. ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket.

A postpartum patient would be at increased risk for postpartum hemorrhage if she delivered a(n) a. 5-1b, 2-oz infant with outlet forceps. b. 6.5-1b infant after a 2-hour labor. c. 7-1b infant after an 8-hour labor. 8-1binfantaftera12-hour labor.

a. ANS: B A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction. Delivering a 5-1b, 2-oz infant with outlet forceps would put this patient at risk for lacerations due to the use of forceps. A 7-1b infant after an 8-hour labor is a normal labor progression. Less than 3 hours is considered a rapid labor and can produce uterine muscle exhaustion. An 8-1b infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid birth and may cause the uterine muscles failure to contract.

A multiparous patient is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the patient void and massages her fundus; however, the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next? a. Recheck vital signs. b. Insert a Foley catheter. c. Notify the health care provider. Continue to massage the fundus

a. ANS: C Treatment of excessive bleeding requires the collaboration of the health care provider and the nurses. Do not leave the patient alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The patient has voided successfully, therefore a Foley catheter is not needed at this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.

Fran delivered a 9 lb, 10 oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch diameter puddle of blood. What is your first action? a.Call for help b.Assess the fundus for firmness c.Take her blood pressure d.Check the perineum for lacerations

b.Assess the fundus for firmness

A patient is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? •1. Methergine •2. Stadol •3. Misoprostol •4. Betamethasone

•1. Methergine •3. Misoprostol

The charge nurse is assessing several postpartum patients. Which patient has the greatest risk for postpartum hemorrhage? •1. The patient who was overdue and delivered a 7lb 10oz baby vaginally •2. The patient who delivered by scheduled cesarean delivery •3. The patient who had oxytocin augmentation of labor •4. The patient who delivered vaginally at 36 weeks

•2. The patient who delivered by scheduled cesarean delivery

To assess the healing of the uterus at the placental site, the nurse assesses: •1. Lab values. •2. Blood pressure. •3. Uterine size. •4. Type, amount, and consistency of lochia.

•4. Type, amount, and consistency of lochia.

•A nurse is caring for a client who is 4 hours postpartum with postpartum hemorrhage. Which nursing diagnosis has the highest priority? •Knowledge Deficit, related to lack of information about signs of postpartum hemorrhage •Deficient fluid volume, related to blood loss secondary to uterine atony •Fatigue, related to anemia from postpartum bleeding •Activity Intolerance, related to enforced bedrest to control postpartum bleeding

•Deficient fluid volume, related to blood loss secondary to uterine atony

•Which of the following herbs can be utilized to increase a mother's milk supply while breastfeeding? •Cohosh •Fenugreek •Horseradish •Kava kava

•Fenugreek