final study guide 75

The nurse on a postpartum unit focuses on how to assist the father in identifying his role with the neonate. Which intervention by the nurse is most helpful? Pg 434 1. Encourage the couple to identify mutual expectations of the fathering role. 2. Critique the father's methods of providing physical care for the neonate. 3. Provide written materials about the physical and emotional role of a father. 4. Observe for a competitive attitude between the parents about providing baby care.

1 -Mutually agreed-upon fathering expectations, shared by the couple, can decrease the level of stress within the relationship.

The labor and delivery nurse understands that some neonates spontaneously take a breath once the head and chest are delivered. Which understanding does the nurse have for the neonate that requires chemical stimuli to breathe? Page 483 1. Mild hypoxia and decreased pH stimulate the brain. 2. Carbon dioxide is administered in small doses. 3. Oxygen is applied immediately to start respirations. 4. Suctioning is used to stimulate breathing efforts.

1 The essence of chemical stimulation to initiate neonate breathing is the mild hypoxia that occurs when placental blood flow stops. Hypoxia causes an increase in carbon dioxide and decrease in blood pH, a chemical reaction that stimulates the respiratory center in the medulla.

A nurse is teaching her patient about formula feeding. All of the following statements are correct except which one? Pg 542 1. Store unmixed powder in the refrigerator. 2. Freezing mixed formula is not recommended. 3. Once you prepare a bottle of formula it must be kept refrigerated and used within 24 hours. 4. Discard unused formula remaining in the bottle at the end of a feeding.

1 Unmixed powder formula should not be refrigerated.

The nurse is providing care for a neonate born to a mother with preexisting diabetes mellitus. Which neonatal assessment findings can the nurse expect? Select all that apply. Pg 573 1. Heart murmur 2. Hypoglycemia 3. Respiratory distress 4. Birth weight over 4,000 gm 5. Hyperglycemia

1,2,3,4 A heart murmur is commonly heard in infants of diabetic mothers due to cardiac anomalies. (2) Hypoglycemia (not hyperglycemia) is an expected assessment finding in neonates born to mothers with preexisting diabetes mellitus. (3) Tachypnea and respiratory distress are expected assessment findings in neonates born to mothers with preexisting diabetes mellitus. (4) Macrosomia, defined as birth weight greater than or equal to 4 kg, is an expected assessment finding in neonates born to mothers with preexisting diabetes mellitus

The nurse is preparing to teach the postpartum mom about newborn feeding cues. Which of the following behaviors of the infant would be appropriate feeding cues to include? Select all that apply. Pg 535 1. Smacking their lips 2. Extending their tongue 3. Putting their hand to their mouth 4. Entering a quiet alert stage 5. Turning their head to their mother's voice

1,2,3,4,5 Smacking lips is a newborn feeding cue. (2) Extending their tongue is a newborn feeding cue. (3) Putting their hand to their mouth is a newborn feeding cue. (4) Entering a quiet alert stage is a newborn feeding cue. (5) Turning their head to their mother's voice is a newborn feeding cue.

The nurses in a postnatal unit are aware of the fears of new parents with regard to infant abduction. Which interventions by the nurse will alleviate the concerns of the parents? Select all that apply. Page 511 1. Allow only visitors with identification to enter the unit. 2. Use the hospital abduction alarm systems. 3. Require all hospital personnel to wear name tags. 4. Footprints and a photo of the neonate are taken for identification purposes. 5. Encourage parents to accompany persons transporting the newborn.

1,2,4,5

In order to pass the infant care seat challenge, the premature neonate must be able to maintain adequate oxygenation, heart rate, and respiratory rate during the trial. The nurse is preparing for the discharge of a neonate who was born prematurely. Which examinations or screenings must be done before discharge? Select all that apply. Pg 584 1. Eye examination 2. Hearing screen 3. Swallow study 4. Congenital heart disease screening 5. Car seat challenge.

1,2,4,5 An eye examination is done before discharging a neonate born prematurely. (2) A hearing screening is done before discharge. (4) A congenital heart disease screening is done before discharge to rule out some congenital heart defects. (5) A car seat challenge is done to ensure that the infant can safely ride in a car seat without respiratory compromise.

A neonate is born after 37 weeks' gestation, and the nurse is concerned about avoiding cold stress after discharge. Which suggestions does the nurse give the mother to keep the baby safe? Select all that apply. Page 486 1. Keep the baby wrapped in a warm blanket. 2. Perform the daily bath in a warm location. 3. Change wet clothing immediately. 4. Place a stocking cap on the neonate's head. 5. Position the baby away from outside walls and windows.

1,3,4,5

The nurse-manager on a labor and delivery unit is monitoring the reasons for cesarean births at the facility. Which reasons contribute to the high rates of cesarean births? Select all that apply. 1. Fetuses in breech position unable to deliver vaginally 2. Decreasing rate of malpractice litigation with cesarean birth 3. Incidences of women of older maternal age getting pregnant 4. Increased number of elective or maternal request cesareans 5. Presence of nonreassuring fetal tracings during labor

1,3,4,5

During the fourth stage of labor, which actions by the nurse will promote parent-newborn attachment? Select all that apply.Page 509-510 1. Delay administration of eye ointment until parents have held the newborn. 2. Stay close with the couple and the neonate in case of an emergency. 3. Space out necessary assessments to prevent prolonged interruptions. 4. Initiate skin-to-skin contact with a warm blanket over the neonate and parent. 5. Explain expected neonatal characteristics such as molding, milia, and lanugo.

1,4,5 Once ointment is administered, the neonate is less likely to open the eyes and make eye contact with parents. The administration can be delayed. (4) The nurse can initiate skin-to-skin contact with a warm blanket over the neonate and parent. (5) The nurse can point out and explain expected neonatal characteristics such as molding, milia, and lanugo. Understanding the characteristics of their neonate will aid in bonding. The parents may be reluctant to ask about physical characteristics.

The patient is having contractions every 3 minutes and was found to have a platypelloid pelvis upon examination. The fetus has an estimated fetal weight of 7 lbs. and is in the left occiput anterior (LOA) position. This patient is laboring on the birth ball, and her mother-in-law is helping her labor. The nurse is concerned about the five Ps and their effect on the patient's labor. Which P is the nurse most likely concerned about based on the patient's history? 1. Passenger 2. Passage 3. Position 4. Psyche

2 -A platypelloid pelvis is found in only 3% of women and is not an optimal pelvis for the passage of a vaginal delivery.

The lactation nurse takes a phone call from a mother who is breastfeeding her 2-month-old infant. The mother reports an area of redness and warmth on the breast and a painful burning sensation when breastfeeding. Which statement by the nurse is correct if mastitis is suspected? Page 463 1. "If your nipples are cracked, you will need to stop breastfeeding." 2. "Continuing to breastfeed will help clear up the condition." 3. "The baby gave you an infection and needs to be on antibiotics." 4. "Pump your milk and throw it away until the infection is gone."

2 Mastitis is generally self-limiting, and continued breastfeeding can help clear up the infection and condition. If antibiotic therapy is indicated, the infection generally resolves within 24 to 48 hours of antibiotic therapy.

The initial drug of choice for excessive bleeding in the immediate postpartum period is: PAGE 454 1. Methylergonovine maleate (Methergine) IM 2. Oxytocin IV infusion 3. Prostaglandin 15-MF2α suppository 4. Misoprostol

2 Oxytocin IV is the initial drug of choice for excessive bleeding in the immediate postpartum period.

The nurse is providing care for a patient who is 8 hours' postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4-cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take? Page 459 1. Continue to apply ice to the area for 24 hours. 2. Contact the primary care provider (PCP) for further evaluation. 3. Monitor vital signs and report any abnormal readings. 4. Relieve pressure by placing the patient in a side-lying position.

2 The PCP needs to be contacted about assessment findings; the hematoma may need to be evaluated further or evacuation of the hematoma should be performed

A mother of a premature infant in the neonatal intensive care unit (NICU) asks the nurse when her baby will begin oral feedings. The nurse is aware that multiple criteria must first be met. Which criterion is most essential? Pg 516 1. The infant is able to demonstrate hunger cues. 2. The infant exhibits cardiorespiratory regulation. 3. The infant is able to maintain a quiet alert state. 4. The infant is able to demonstrate a stable suck, swallow, breathe pattern.

2 The nurse will observe the neonate for signs of respiratory distress, such as apnea, bradycardia, and oxygenation, as well as feeding tolerance. The neonate needs to exhibit cardiorespiratory regulation before oral feedings are started. This is the most essential condition for oral feedings.

A patient at 35 weeks' gestation arrives at the prenatal clinic in physical distress. Assessment reveals hypotension, thready pulse, shallow respirations, pallor, cold and clammy skin, and anxiety. The nurse does not find evidence of vaginal bleeding but suspects placental abruption. For which reason does the nurse call for emergency transport to the hospital? Select all that apply. 1. The patient reports a recent bout with nausea and vomiting. 2. The patient has all the symptoms of hypovolemia. 3. The absence of blood can indicate a concealed hemorrhage. 4. The patient and fetus are at risk of death from hypovolemic shock. 5. The patient states a sudden onset of severe symptoms.

2,3,4,5 pg 254

The nurse is preparing to teach a class on the benefits of breastfeeding for infants. Which benefits will the nurse include in the presentation? Select all that apply. Pg 532 1. Immunity to respiratory syncytial virus 2. Fewer cases of necrotizing enterocolitis 3. Less likely to develop cancer as adults 4. Decreased risk for developing otitis media 5. Decreased incidence of sudden unexpected infant death (SUID)

2,4,5 Breastfed infants have fewer cases of necrotizing enterocolitis. (4) Breastfed infants have a decreased risk for developing otitis media. (5) There is a decreased incidence of SUID in infants who are breastfed.

The nurse is preparing a talk with new parents about immunity and their newborns. Which factual information will the nurse present? Select all that apply. Page 489 1. Antigens are produced as part of natural immunity. 2. A vaccination is an example of acquired immunity. 3. Placental transfer is how newborns get natural acquired immunity. 4. Gamma globulin is an example of artificial active immunity 5. Natural passive immunity protects the baby for a few months after birth.

2,5

The nurse preparing for the discharge of a premature neonate explains to the parents that the neonate must be able to pass the infant car seat challenge before discharge home. For which reason would the neonate be considered unsafe in a car seat? Pg 584 1. The neonate requires prescribed oxygen therapy at all times. 2. The parents are reluctant to use the car seat because of the small size of the baby. 3. The infant is unable to maintain adequate oxygenation, heart rate, and respiratory rate during the trial. 4. The neonate appears uncomfortable and is fussy for the entire duration of the trial.

3

The patient is a 26-year-old G1P0 at 38 weeks, 2 days of gestation. She is at her provider's office for a visit and complains to the nurse of wrist pain, fatigue, increased discharge, and "feeling heavy." Which complaint could be a sign of impending labor? 1. Wrist pain 2. Fatigue 3. Heavy feeling 4. Increased discharge

4 -. When labor is impending, the patient may lose her mucous plug or have a change in discharge.

The nurse is assisting a newborn's primary care provider (PCP) with the performance of a circumcision. Which intervention is used to manage the neonate's pain? Page 515 1. A Velcro tourniquet is loosely wrapped around the penis. 2. The neonate is given acetaminophen 3 hours before the procedure. 3. The foreskin is numbed with ice before the nerve block. 4. A sucrose-dipped pacifier is offered during the nerve block.

4 A sucrose-dipped pacifier is offered during the nerve block as a procedure for pain management. The sucrose entices the neonate to suck, which is a comforting activity

Page: 556 Heading: Bronchopulmonary Dysplasia __________ is a chronic lung problem that affects neonates who have been treated with prolonged periods of mechanical ventilation and oxygen therapy.

Bronchopulmonary dysplasia Pg 556

A patient who is 8 months' postpartum arrives for an obstetrics (OB) appointment. The nurse notices that both the patient and the infant appear unkempt. The nurse anticipates a diagnosis of Page 473

-postpartum depression

The neonatal intensive care unit (NICU) nurse is providing care for a premature neonate born at 26 weeks' completed gestation who is experiencing respiratory distress syndrome (RDS). Which assessment finding indicates to the nurse that the neonate's respiratory status is deteriorating? Pg 555 1. Pronounced audible expiratory grunting is heard. 2. PaO2 is 65 and PaCO2 is 45 mm Hg. 3. Respiratory rate is 58 breaths per minute. 4. Heart rate is 162 beats per minute.

1

The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, "I think that my baby is deformed inside and we have to fix him." Which risk factor is most strongly related to possible postpartum psychosis (PPP)? Page 472 1. Personal history of bipolar disorder 2. Separation from the baby's father 3. Prolonged labor resulting in cesarean 4. Loss of first child from a heart defect

1

The nurse on a postpartum unit is focused on providing care that will assist the mother and father in making the transition to parenthood. For which reason does the nurse review the prenatal and labor records? Pg 431 1. Pregnancy and birth experiences, which can either enhance or impede the process of becoming a mother 2. Awareness of prenatal classes that will help identify and focus on learning needs of both parents 3. Identification of preexisting maternal conditions that may interfere with parenting transitions 4. Knowledge regarding questions and concerns the mother and father may have about neonate issues.

1 -The nurse reviews the maternal prenatal and labor records because pregnancy and birth experiences can either enhance or impede the process of becoming a mother. The nurse is looking for factors such as complications during pregnancy, labor, and birth

The nurse notices that a neonate being treated for hyperbilirubinemia with phototherapy has had a daily increase of total bilirubin serum levels greater than 5 mg/dL for the past 2 days. The neonatal care provider prescribes an exchange transfusion. Which knowledge does the nurse apply to the procedure? Pg 567 1. There is a risk of encephalopathy which can cause neurological deficits. 2. Approximately 50% of the neonate's red blood cells (RBCs) are replaced. 3. Donor RBCs are obtained from the neonate's mother. 4. The procedure is exclusive to pathological jaundice.

1 A complication of hyperbilirubinemia is acute bilirubin encephalopathy (ABE) and kernicterus, an abnormal and irreversible accumulation of unconjugated bilirubin in the brain cells. Bilirubin accumulates within the brain and becomes toxic to the brain tissue, causing neurological disorders

A patient who is pregnant does not remember the last date of her menstrual period. In which manner does the nurse expect the estimated date of delivery (EDD) to be determined for this patient? 1. Having an ultrasound examination 2. Using the gestational wheel 3. Asking when previous babies were born 4. Obtaining a history of gestational length

1 A fetal ultrasound will provide information about the fetal development, allowing for an accurate estimated date of delivery (EDD). The nurse expects this manner of determination

The patient is having an unmedicated childbirth and has begun to bear down. She vocalizes, "The baby is coming!" Which action should the nurse take? 1. Have the patient assume a comfortable and upright position. 2. Help the patient onto all fours. 3. Help the patient in a lithotomy position. 4. Help the patient into a knee-chest position.

1 An upright position allows gravity to assist with the descent of the baby

4. A patient is in her first trimester of her second pregnancy. The patient's first child was born with a trisomy 21 defect. The patient is requesting testing to determine whether the current fetus has the same defect. Which initial testing does the nurse expect the HCP to prescribe? 1. Fetal ultrasound 2. Magnetic resonance imaging 3. Chorionic villa sampling 4. Amniocentesis

1 Fetal ultrasound in the first trimester of pregnancy can be performed for nuchal translucency, which measures the midsagittal plane with the neck of the fetus to assess the amount of fluid behind the neck. An elevated measurement is associated with trisomy 21. This is the initial test the nurse can expect; results may require further diagnostic testing

The mom in Room 8 delivered 2 hours ago. The newborn nursed for 20 minutes after delivery and is now sleeping quietly. She asks when she should feed the baby again. Your best response is: Pg 534 1. Teach to observe for feeding cues and encourage her to offer her breast at least every 2 to 3 hours or on demand. 2. Teach to observe for feeding cues and encourage her to offer her breast only when the baby initiates a feeding. 3. Encourage her to offer the breast on demand and to supplement with formula if the baby shows feeding cues every hour. 4. Encourage her to offer her breast at least every 4 hours and gently awaken the infant as needed.

1 Hunger cues may be present for up to 30 minutes so encourage mothers to observe for feeding cues and encourage her to offer her breast at least every 2 to 3 hours or on demand.

The nurse is providing care for an infant in the neonatal intensive care unit (NICU) diagnosed with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Which specific intervention does the nurse expect for this neonate? Pg 558 1. Maintain fluid restrictions. 2. Obtain blood glucose levels. 3. Monitor hemoglobin and hematocrit levels. 4. Administer enteral feedings.

1 Maintaining fluid restrictions is specific for the neonate with BPD and PDA, as these conditions can lead to pulmonary edema.

The nurse works in a postnatal nursery and is required by hospital policy to perform a gestational age assessment on specified neonates. On which neonate is the nurse most likely to perform this assessment? Page 490 1. The neonate of a diabetic mother 2. The neonate born at 41 weeks' gestation 3. The neonate born after an 18-hour labor 4. The neonate exposed to oxytocin in utero

1 Neonates who are born of diabetic mothers will commonly have gestational age assessments done.

The parents of a newborn male are concerned about providing care for the baby's new circumcision performed with a Plastibell. Which information will the nurse include in the teaching plan for the parents? Page 516 1. Report if penis is red, warm, and swollen, or if there is surgical site drainage. 2. Remove the plastic ring gently on the fifth day after surgery. 3 Apply lubricants to the penis to keep the diaper from sticking 4. Contact the health-care provider (HCP) if the newborn does not void for 36 Hours.

1 The nurse will include information to the parents that if the entire penis is red, warm, and swollen or there is drainage from the surgical site (signs of infection), it should be reported immediately to the HCP

The nurse in the neonatal nursery notices a neonate, born 35 minutes ago, is unresponsive to external stimuli, and has a respiratory and heart rate slightly below normal range. Which action does the nurse take? Page 505 1. Allows the neonate to naturally continue deep sleep. 2. Picks up the neonate and tries to get a response. 3. Asks another nurse to assist with reassessment. 4. Notifies the caregiver of the neonate's condition.

1 This period of relative inactivity (deep sleep) begins approximately 30 to 40 minutes after birth. Heart rate and respiratory rate decrease and can fall slightly below the normal range. The nurse needs to allow the neonate to continue to sleep deeply, which will last for approximately 2 hours.

The nurse in a postpartum unit evaluates new parents for risk factors that can indicate problems with bonding or attachment. Which situations does the nurse recognize as a cause for bonding or attachment problems? Select all that apply. Pg 437 1. The mother experienced eclampsia in the third trimester of pregnancy. 2. The neonate is being treated for meconium aspiration syndrome (MAS). 3. The mother experienced dystocia in the second phase of labor. 4. The father of the neonate is in the military and not yet home on leave. 5. The mother's mother lives next door and is available to help with the baby.

1,2,3 -The nurse recognizes the mother who experienced eclampsia in the third trimester of pregnancy as being at risk for bonding/attachment problems. (2) The nurse recognizes the mother whose neonate is being treated for MAS as being at risk for bonding/attachment problems. The mother is likely to be separated from the neonate. (3) The nurse recognizes the parents of a neonate may experience bonding/attachment problems if the mother experienced dystocia in the second stage of labor. The condition is likely to have caused a long and exhaustive labor for both parents.

The nurse is aware of concern about the increasing numbers of severe maternal morbidity (SMM). It is believed to be related to changes in the overall health of the population of women giving birth. Which reasons does the nurse identify as causes of SMM? Select all that apply. Page 450 1. Increases in maternal age 2. Prepregnancy obesity 3. Inability to pay for health care 4. Cesarean deliveries 5. Preexisting chronic medical conditions

1,2,4,5 -Documented increases in maternal age are a likely cause for SMM; older women have increased risk. (2) Obesity is a general health risk in the United States; prepregnancy obesity causes increased incidences of SMM. (4) Due to improved diagnostic technology and increased litigation related to childbirth, cesarean deliveries are increasing. Surgical procedures always carry a risk for complications. (5) Preexisting chronic medical conditions are a contributor to the increasing rates of SMM. Due to a decrease in overall general health of women, complications are more likely.

The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of "becoming a mother." For which cultural influences does the nurse assess? Select all that apply. Pg 432 1. What amount of time the mother spends in each phase 2. Differences in the mother's expectation related to ability to rest 3. How the mother physically recovers from labor and delivery 4. Mother's involvement in decision-making for the first few months 5. Whether the mother seems interested in how to care for her baby

1,2,4,5 -The amount of time the mother spends in each phase of "becoming a mother" can be influenced by culture. (2) The expectation of some cultures is that the mother should rest in the postpartum period or longer rather than be focused on care of the baby. (4) The expectation of some cultures is that the mother does not need to be focused on decision-making about the baby for the first few months of the infant's life. (5) Whether a mother is interested in learning how to care for her neonate may be culturally influenced. In some cultures, the mother's mother and other family members will provide care for the infant for several months. The nurse does need to assess whether the lack of interest is culturally based or a sign of other issues.

The postpartum nurse is preparing to present infant care information to a couple who expresses concern about when to bathe their newborn. Which behaviors will the nurse present as general guidelines? Select all that apply. Page 516 1. Daily bathing with soap is not necessary for the newborn. 2. Bathing is best after a feeding when the newborn is relaxed. 3. Use a mild preservative-free soap with a neutral pH. 4. Avoid the use of soap on the face of the newborn. 5. Genital and rectal areas should be cleaned at each diaper change.

1,3,4,5

A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient's medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply. Page 465 1. Neonatal macrosomia 2. Low-grade fever (101.3°F [38.5°C]) 3. Poor oral fluid intake 4. Urinary catheter during labor 5. Use of a vacuum extractor

1,3,4,5 -Neonatal macrosomia, which can cause edema around the urethra, is a risk factor for UTI. (3) The postpartum patient needs to drink a minimum of 3,000 mL/day; poor oral fluid intake is a risk factor for UTI. (4) Urinary catheter inserted during the labor process is a risk factor for UTI. (5) Operative vaginal deliveries, forceps, or vacuum extractor, which can cause edema around the urethra, is a risk factor for UTI.

The premature neonate is susceptible to skin breakdown because of thin, immature skin. Which skin care interventions are appropriate for the premature neonate? Select all that apply. Pg 552 & 558 1. Use a neutral pH cleanser and sterile water for bathing. 2. Provide a full bath every day. 3. Use adhesives to secure medical devices. 4. Change the neonate's position at least every 4 hours. 5. Place a hydrocolloid barrier underneath medical devices.

1,4,5 Use a neutral pH cleanser and sterile water for bathing to help prevent skin breakdown on a premature neonate. (4) Changing positions frequently, at least every 4 hours, helps prevent skin breakdown in premature neonates. (5) Hydrocolloid products serve as a protective layer under medical devices, helping to prevent skin breakdown in premature neonates.

The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit? Pg 431 1. Satisfaction questionnaires 2. Alterations in terminology 3. Decrease in nurse/patient ratios 4. Soliciting paternal expectations

2 -Rubin and Mercer have addressed the terminology used regarding the mother during early postpartum. From "maternal phases" and "maternal touch" (Rubin), terminology was changed by Mercer to "maternal role attainment" and finally to "becoming a mother." This change can be easily implemented by the nurse and promote a change in the unit culture.

The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis? 1. To prevent uterine prolapse 2. To prevent uterine inversion 3. To prevent uterine hemorrhage 4. To prevent uterine movement

2 -When palpating the patient's uterus 12 hours' postpartum, the nurse supports the lower uterine segment by placing one hand just above the symphysis pubis. Pregnancy stretches the ligaments that hold the uterus in place, and fundal pressure could result in uterine inversion.

The nurse in the neonatal intensive care unit (NICU) is assessing a neonate delivered at 28 gestation. Which of the following findings is the nurse's greatest concern? Pg 550 1. Presence of a heart murmur 2. Apnea 20 seconds or longer 3. Low hemoglobin laboratory level 4. Absent or weak reflexes

2 Apnea for 20 seconds or longer is the nurse's greatest concern. Even though this is expected in premature neonates, the nurse will still focus on ABCs (airway, breathing, circulation).

The nurse is assessing a term neonate delivered to a mother with a history of drug and alcohol abuse. Which finding does the nurse relate to the mother's history? Page491 1. Chest circumference is less than the head circumference. 2. Head circumference is below the 10th percentile of normal for gestational age. 3. When crying, the neonate exhibits an absence of tear production. 4. The neonate's pulse rate increases when the neonate cries.

2 Head circumference below the 10th percentile of normal for gestational age is indicative of microcephaly, which is often related to congenital malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy

The nurse is providing care for a neonate during the fourth stage of labor. Which action does the nurse take during this stage? Page 509 1. Complete the neonate assessment within the first hour. 2. Dry the neonate immediately after birth. 3. Obtain neonate blood glucose levels as soon as possible. 4. Perform Apgar screening until scores are 7.

2 The fourth stage of labor is from the birth of the neonate for 4 hours postpartum. The nurse will dry the neonate immediately to aid with thermoregulation and to prevent cold stress.

A patient who is at 42 weeks' gestation is concerned when the primary care provider (PCP) decides to induce labor. Which reason does the nurse explain as the most important need for this procedure? Pg 543 1. Risk of hypoglycemia due to macrosomia 2. Fetal hypoxia due to placental insufficiency 3. Likelihood of meconium aspiration 4. Risk of hypothermia due to loss of fetal subcutaneous fat

2 The greatest reason to induce labor for a postmature fetus is to minimize complications related to placental dysfunction. Fetal hypoxia results from decreased placental function. This is the most important reason for labor induction.

The nurse is providing care for a patient at 30 weeks gestation. Which topic related to patient concern or discomfort is most important for the nurse to address? 1. Increased breast enlargement 2. Dizziness when lying supine 3. Dependent edema and varicosities 4. Hyperpigmentation on the face

2 The most important issue for the nurse to address is the patient's experience of dizziness when lying supine. The nurse will provide education about supine and orthostatic hypotension and advise the patient to refrain from supine positioning. The patient needs to be instructed to use side-lying positions.

The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider (PCP)? Select all that apply. Page 469 1. Mild headache 2. Hot, red, painful breasts 3. Foul-smelling lochia 4. Not sleeping well 5. Frequent, painful urination

2,3,5 All signs of infection

The nurse is assessing a patient who is 36 hours' postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply. Page 266 1. Temperature that increases from 99.8°F to 100.5°F 2. Increased margins of incisional redness 3. Incisional tenderness with palpation 4. Serosanguinous drainage from the suture line 5. Notably warm skin around the incision

2,5 -. An increase in redness in the incisional margins is a likely sign of developing wound infection. (5) When the skin around a surgical incision is notably warm to the touch, it is likely a sign of a developing wound infection

The labor and delivery nurse is present for the delivery of a neonate born at 30 weeks' completed gestation. Which action by the nurse is most important? Pg 551 1. Stabilize and transfer the neonate to the neonatal intensive care unit (NICU). 2. Review the pregnancy history for risk factors. 3. Provide a neutral thermal environment (NTE). 4. Maintain fluid and electrolyte balance.

3 When attending a premature birth, the most important nursing action is to provide an NTE. The premature neonate is at risk for increased loss of heat because of thin, immature skin and diminished amounts of subcutaneous fat. The nurse needs to take measures to prevent cold stress, which can be fatal.

The postpartum nurse is planning a home visit to a mother who delivered her baby 1 week ago. Which finding indicates to the nurse a possible problem with mother-infant bonding? Pg 433 1. The mother is pleased to have the nurse visit her home and baby. 2. The baby's grandmother is present and involved with mother/baby care. 3. The mother focuses the visit on her physical recovery and concerns. 4. The baby's father is on "paternity leave" and involved with the baby.

3 -After the first 48 hours' postpartum, the mother moves into the "taking hold" phase when the mother's focus moves from self to the infant. When the mother focuses the nurse's attention on the mother's physical recovery and concerns, the nurse needs to assess for problems with mother-infant bonding

The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform before assessing the patient's uterus? 1. Place the patient on the left side. 2. Administer a dose of oxytocin. 3. Ask the patient to void. 4. Assess the passage of lochia.

3 -The nurse needs to have the patient void before palpating the uterus in order to accurately assess uterine placement and tone. An overdistended bladder can result in uterine displacement and atony

The nurse is closely monitoring a patient who is postpartum and at risk for postpartum hemorrhage (PPH). Which assessment finding will cause the nurse to contact the primary care provider (PCP) immediately? Page 455 1. The uterus is displaced. 2. The uterine fundus is boggy. 3. Peripad weighs 100 g within 15 minutes. 4. Small clots are expressed with massage.

3 -The nurse will monitor the amount and characteristics of each patient's lochia. If bleeding seems excessive, the nurse will weigh peripads to ascertain the amount of blood loss. This patient's estimated blood loss is 100 mL in 15 minutes (1 g = 1 mL of blood). The nurse will contact the PCP and report PPH

The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management? Page 466 1. Application of hot packs to the perineal area 2. Instructions to improve circulation by ambulating 3. Information applicable to medication therapy 4. Medicating for pain above level 4 on a 0 to 10 scale

3 -The nurse will need to provide applicable discharge teaching for both antibiotic and analgesic therapy. Antibiotics need to be taken as ordered and until they are gone.

The nurse is providing care for a new mother during a follow-up visit 6 weeks after a vaginal delivery. The mother begins to cry and reports difficulty with eating and sleeping. The nurse identifies postpartum blues and cites which reason as the most likely cause? Pg 442 1. Fatigue related to a "fussy" baby 2. Frustration over physical appearance 3. Changes in hormonal levels 4. Stress related to new mother role

3 Although the other options can contribute to postpartum blues, the most likely cause is changes in hormone levels.

A neonatal intensive care unit (NICU) nurse is providing care for a premature neonate born at 27 weeks' completed gestation in the delivery room. Which intervention would the nurse prepare to do in the delivery room to maintain a neutral thermal environment (NTE) for the neonate? Pg 551 1. Initiate skin-to-skin immediately after birth. 2. Dry the infant vigorously with prewarmed linen. 3. Place a polyurethane plastic wrap over the neonate's torso and extremities. 4. Place the neonate directly on a chemical warming mattress.

3 Placing plastic barriers made of polyethylene over preterm neonates (less than 32 weeks' gestation) after birth prevents heat loss by decreasing transepidermal water loss (TEWL). This supports the maintenance of an NTE.

The nurse is presenting information to new parents regarding the screening of their newborn. Which information does the nurse identify as being most important to the parents? Page 512 1. All babies born in the United States are screened for specific conditions. 2. Newborn screenings consist of a blood test and a hearing test. 3. Screenings are done to identify genetic diseases and inherited disorders. 4. Each state has statutes or regulations on newborn screening.

3 The blood test screens for infections, genetic diseases, and inherited and metabolic disorders; this is the information the parents of a newborn will be most interested in. Parents are focused on the well-being of their newborn and will seek information that provides conditions and treatments if needed.

The nurse is assessing a newborn's reflexes. Which response will cause the nurse concern? Page 503 1. A positive tonic neck reflex 2. Absence of rooting or sucking reflexes 3. Asymmetrical Moro reflex 4. Strong Babinski reflex

3 The nurse is concerned if an asymmetrical response is noted when checking for a Moro reflex. This response may be related to temporary or permanent birth injury to the clavicle, humerus, or brachial plexus. This reflex disappears by age 6 months.

A patient in the second trimester of pregnancy becomes upset when the health care provider (HCP) schedules several screening tests. The patient voices concern that something is wrong with her baby. Which statement by the nurse will reduce the patient's anxiety? 1. "Multiple screening tests are ordered for every pregnancy." 2. "It is better to identify problems before birth than afterward." 3. "Screening tests are primarily to identify those without disease or abnormality." 4. "Diagnostic testing is a reason for worry because they indicate fetal problems."

3 The truthful statement that screening tests are primarily to identify those without disease or abnormality will alleviate the patient's anxiety

A patient delivers a term neonate and expresses concern about the reason for giving the neonate an injection. Which information from the nurse is accurate? Page 487 1. Neonates will hemorrhage without vitamin K. 2. Mothers are unable to supply vitamin K to the fetus. 3. Vitamin K is needed to activate clotting factors. 4. Mothers on certain medications do not provide enough vitamin K to infants through breastfeeding.

3 Vitamin K is given to the neonate in order to activate coagulation factors II, VII, IX, and X, which are synthesized in the liver

The nurse is teaching the mother of a neonate the benefits of kangaroo care. Which action is explained to the mother regarding the procedure? Pg 534 1. The neonate is tucked into the front of a parent's shirt. 2. A pouch is formed from a blanket for carrying the neonate. 3. A bare-chested neonate is held against a bare-chested parent. 4. The neonate is placed in a sling and placed on a parent's side.

3 When the nurse teaches a mother the benefit of initiating kangaroo care, a bare-chested neonate is held against a bare-chested parent (skin-to-skin) and both the neonate and parent are covered with a warm blanket.

A new mother states, "I don't want anyone around my baby. I need to protect him from getting sick." Which statement by the nurse will help the mother to understand neonatal immunity? Select all that apply. Page 489 1. "I agree with you; the baby's sterile environment is gone." 2. "The baby will have acquired immunity soon from vaccinations." 3. "The baby has natural passive immunity from you for a few months." 4. "Babies start to establish gut flora after birth which helps to provide protection against gastrointestinal (GI) infections." 5. "Your baby was exposed to some pretty serious pathogens in your birth canal."

3,4 The neonate does have natural passive immunity from the mother for the first few months. Natural passive immunity is the placental transmission of antibodies from the mother to the fetus. (4) The establishment of gut flora helps provide protection against GI infections.

A patient has experienced an uneventful pregnancy but begins to have vaginal spotting at 38 weeks gestation. The health care provider (HCP) suspects placenta previa initiated by cervical thinning. Which testing does the nurse expect the HCP to schedule? 1. Doppler flow studies 2. Nonstress testing 3. Magnetic resonance imaging 4. Ultrasonography studies

4 Ultrasonography studies are appropriate in determining placental placement and possible abnormalities.

The nurse is reading the patient's chart, which indicates the patient has a "gynecoid pelvis." What finding is expected in this patient? 1. Narrower pubic arch 2. Shorter diameter between her coccyx and ischium 3. Smaller inlet 4. Wider outlet

4 -A gynecoid pelvis has a wider outlet than an android pelvis. The nurse is caring for a 31-year-old female patient who is pregnant at 37 weeks and 5 days' gestation.

The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care? Pg 434 1. The grandparents decided they want to be involved. 2. The parents need to discuss their expectations of each other. 3. The mother is determined the father should be involved. 4. Information must be presented on an age-appropriate level.

4 -Learning styles and teaching strategies are different for young teens and older teens. Information needs to be provided in a manner that will engage the adolescent parent in the learning process. This is the most important factor for the nurse to consider.

A new mother expresses frustration about how to know what her baby wants. The mother states, "I don't know what I expect, but then, the baby doesn't know either." Which situation does the nurse use as an example of neonate communication? Pg 440 1. The baby is content to lie still on the mother's abdomen. 2. The baby is easily awakened if irritated by loud noises. 3. The baby resists eye contact if bored or disinterested. 4. The baby roots for the breast when the cheek is stroked.

4 -Rooting is an initial interaction that elicits the desire/need to eat. When a neonate's cheek is stroked, the neonate turns the head toward the touch and begins to root for the breast. The mother needs to understand this is the neonate's method of communication.

The nurse is providing care for a primiparous patient in active labor. Cervical dilation has progressed 0.5 cm in 2 hours. The intrauterine pressure catheter reading is 20 mm Hg. Which action does the nurse anticipate next? 1. Rupture of uterine membranes by the nurse 2. Preparation for a cesarean delivery due to signs of fetal distress 3. Medicating the patient with pain medication to promote uterine rest 4.Augmentation of labor with oxytocin per health-care provider's (HCP's) order

4 -The action the nurse will anticipate is the augmentation of labor with administration of the prescribed oxytocin.

The postpartum nurse notices that a new mother has her neonate unwrapped and undressed "to check out the baby." For which reason does the nurse conclude the neonate is at risk for cold stress? Page 486 1. The neonate has an increased metabolic rate. 2. The neonate's respiratory rate has dropped. 3. The neonate's skin is cool and clammy 4. The neonate is moving extremities about.

4 A visible manifestation that indicates the neonate may be approaching cold stress is movement of the extremities in an effort to produce body heat.

A breastfeeding mother is planning to return to work 3 months after her baby is born. The mother is planning to use an electric breast pump and freeze some breast milk for use later. Which information does the nurse need to provide? Page 540 1. Breast milk can only be frozen in special plastic freezer bags. 2. Frozen breast milk can be defrosted in a microwave. 3. The freezer door shelf decreases the chance of milk contamination. 4. Breast milk can be kept in a deep freezer for 6 to 12 months.

4 Breast milk can be safely kept in a deep freezer for 6 to 12 months; in a freezer attached to a refrigerator, it can be safely stored for 3 to 6 months.

The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room? PAGE 452 1. Ask the patient how many peripads she considered to be "soaked." 2. Rely on the primary health-care provider's (HCP's) estimate of blood loss. 3. Place a basin at the foot of the delivery table to catch any blood. 4. Collect blood in calibrated, under-buttocks drapes for vaginal birth.

4 Collecting blood in calibrated, under-buttocks drapes for vaginal birth and then weighing the drapes is the easiest way to estimate blood loss in the delivery room

The nurse is teaching newborn care to an adolescent mother. When the nurse attempts to teach how to swaddle the newborn, the mother states, "What's the big deal about how to wrap up a baby?" The nurse needs to convey which reason as being most important for proper swaddling? Page 522 1. Correct swaddling will increase the neonate's comfort. 2. Neonates are swaddled only until they can turn from front to back. 3. Two to three fingers need to fit between the infant's chest and the swaddle. 4. Improper swaddling can cause hip dysplasia.

4 Improper swaddling can cause hip dysplasia. It is especially important to allow the hips to spread apart and bend up. In the womb, the legs are in a fetal position with the legs bent up across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket. This is the most important information for the nurse to convey

The mother of a premature infant in the neonatal intensive care unit (NICU) is encouraged by her baby's nurse to bring expressed breast milk for enteral feedings. For which reason does the nurse encourage the mother to do this? Pg 552 1. The baby will be more likely to breastfeed later. 2. The baby will gain weight faster on breast milk. 3. The mother will feel more involved with her baby. 4. Breast milk helps prevent necrotizing enterocolitis.

4 It is a known fact that babies fed on breast milk are less likely to develop necrotizing enterocolitis.

A patient who is pregnant asks the nurse when her baby is due to be born. The patient reports her last menstrual period (LMP) date as April 14. Using Naegele's rule, the nurse will set the estimated date of delivery (EDD) as what date? 1. July 21 2. January 7 3. July 14 4. January 21

4 Naegele's rule requires counting back 3 months from the LMP and adding 7 days. This is the correct calculation and EDD.

A nurse is caring for a client who is 2 days' postpartum, is breastfeeding, and reports cracked nipples and soreness. The nurse identifies the most common cause of the skin breakdown is related to which of the following? Pg 537 1. Milk let-down caused by oxytocin production in the posterior pituitary gland 2. Nipple confusion due to the use of a pacifier 3. Placing the infant on the breast to feed every 1 to 2 hours 4. Improper latch by the newborn during feedings

4 Poor or shallow latch can lead to nipple soreness, redness, bruising, or skin breakdown.

The nurse is providing care for a patient who is 1 day postpartum and exhibiting symptoms of postpartum psychosis. Which medical management does the nurse expect for this patient? Page 472 1. Prescriptions for antidepressant/antipsychotic drugs 2. Discharge to home with 24-hour observation in place 3. Prescribed neonate visits during inpatient treatment 4. Immediate hospitalization in a psychiatric unit

4 The nurse expects the HCP to immediately hospitalize the patient in a psychiatric unit. Maintaining the patient in the postpartum unit delays necessary psychiatric treatment.

he nurse is explaining to the new breastfeeding mother the types of neonatal stools the mother can expect. Which examples does the nurse provide? Select all that apply. Page 488 1. Residual meconium is passed as loose watery stool. 2. Sticky, thick, black stools indicate a presence of blood. 3. Stools will eventually become drier and more formed. 4. Stools will be golden yellow, with a "seedy" appearance, and a sour odor is expected. 5. A neonate's first stool is passed within the first 12 to 24 hours.

4,5 The stool of a breastfed baby later becomes a golden yellow with a pasty consistency, "seedy appearance," and a sour odor. (5) Meconium stool begins to form during the fourth gestational month and is the first stool eliminated by the neonate. It is first passed within 24 to 48 hours.